Starfield Benefits of Primary Care Evidence from

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 Starfield Source: Starfield, 1998.

Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics – – – First-Contact Longitudinality Comprehensiveness Coordination Family-centeredness Community orientation Source: Starfield, 1998. Starfield

Primary Care Scores, 1980 s and 1990 s 1980 s 1990 s Belgium 0. 8 0. 4 France - Germany 0. 5 United States 0. 4 0. 2 Australia Canada Japan Sweden 1. 2 1. 1 1. 2 0. 9 Denmark 1. 5 Finland 1. 5 Netherlands 1. 5 Spain 1. 7 1. 5 - 1. 1 1. 2 0. 3 0. 4 0. 8 1. 4 Starfield 2000

System and Practice Characteristics Facilitating Primary Care, Early-Mid 1990 s GER FR BEL US SWE JAP CAN FIN AUS SP DK NTH UK Starfield 11/00

Health Care Expenditures per Capita, 1996 Belgium France Germany United States --------- 1693 1978 2222 3708 Australia Canada Japan Sweden --------- 1776 2002 1581 1405 Denmark Finland Netherlands Spain United Kingdom ----------- 1430 1389 1756 1131 1304 Starfield 2000

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

International Comparisons: Birth Outcomes and Primary Care Score Low Average Rankings 14 8 6 High 11. 5 12 10 Med 9. 5 7. 3 4. 8 5. 5 4. 6 Countries with weak primary care infrastructures have poorer health performance. 4 2 0 Low Birth. Weight Post Neonatal Mortality R= -. 38 NS Low: BEL, FR, GER, US Med: AUS, CAN, JAP, SWE High: DEN, FIN, NTH, SP, UK R= -. 74; p<. 001 Source: Starfield & Shi, 2002. Starfield 09/02

Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation All Except Suicide Female Lowest 9. 5 (Belgium, France, Germany, US) Middle 3. 8 (Australia, Canada, Japan, Sweden) Highest 7. 6 (Denmark, Finland, Netherlands, Spain, UK) Suicide All Except External Male Female 10. 8 7. 3 8. 8 10. 8 2. 8 7. 0 7. 3 3. 8 3. 5 7. 4 6. 8 5. 8 8. 2 7. 0 Source: OECD, 1998. Male Starfield 2000

Average Rankings for World Health Organization Health Indicators for Countries Grouped by Primary Care Orientation DALEs Overall Health 16. 3 22. 5 36. 3 4. 8 Lowest Child Survival Equity 16. 5 26. 0 (Belgium, France, Germany, US) Middle* (Australia, Canada, Sweden, Japan) Highest* 11. 0 16. 0 29. 1 15. 8 15. 2 31. 6 (Denmark, Finland, Netherlands, Spain, UK) Source: Calculated from WHO, 2000. Starfield 10/02

Primary Care Features Consistently Associated with Good/Excellent Primary Care • System features – Regulated resource distribution – Government-provided health insurance – No/low cost-sharing for primary care • Practice features – Comprehensiveness – Family orientation Starfield 10/01

Benefits of Primary Care: Within-Country Studies • Ecological analyses: Effect of primary care doctor to population ratios (US, UK) • Case control studies (US) • Hospitalizations for avoidable conditions or complications (US, Spain) • Survey data on impact of affiliation with a primary care doctor (US, Spain) • Path analyses at state and local levels (US) Starfield 09/02

Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians per 10, 000 Population Source: Parchman & Culler, 1994. Starfield 10/02

State Level Analysis: Primary Care and Life Expectancy. . ID . MS . . ID. IA UT. . TN. . TX. . WV DE AR MI. AL . GA . NV . . . AZ. . MT. NJ. . NM. KS FL WI. KY. PA. NC. VA. . SC LA NE SD ME NH RI IL . . CT. . MN. MA WA. CA . ND. OR HI . NY. MD . AK R=. 54 P<. 05 PC physicians/population positively associated with longer life expectancy. Source: Shi et al. , 1999. Starfield 03/02

Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990 Total Mortality . 42** -. 36** Infant Mortality . 35* Income Inequality (Robin Hood Index) -. 29* -. 33* Primary Care Physicians -. 37** Life Expectancy . 58** . 41** -. 17 Source: Shi et al. , 1999. *p<. 05; **p<. 01. Low Birthweight Starfield

Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990 Life Expectancy Total Mortality . 39** -. 38** Neonatal Mortality . 40** -. 35** Income Inequality (GINI COEFFICIENT) -. 18 -. 33* Primary Care Physicians . 16 Stroke Mortality -. 38** Source: Shi et al. , 1999. . 42** . 18 -. 33* Life Expectancy *p<. 05; **p<. 01. Postneonatal Mortality Starfield

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 –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, 2000. Starfield 2000

Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality, 50 US States, 1990 Areas with low income inequality 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 & Starfield, 2000. Starfield 2000

US urban infants 8. 8 Urban health center infants 7. 5 US rural infants 6. 8 Rural health center infants 6. 0 African American urban infants 13. 6 African American urban health center infants African American rural health center infants 10. 4 13. 0 7. 4 0. 0 2. 0 4. 0 6. 0 8. 0 Source: Politzer et al. , 2001. 10. 0 12. 0 14. 0 Starfield 09/02 Racial composition Geographic area Low Birthweight among US Rural, Urban, and Health Center Infants

Primary Care and Health: Evidence-Based Summary • 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 Starfield 09/02

Primary Care and Equity: Evidence-Based Summary In areas with low social inequity, the additional effect of primary care is small. In areas of high social inequity, the additional effect of primary care is larger. Starfield 09/02