General Practice as an Integral Part of the Health

System

Barbara Starfield, MD, MPH

16th Nordic Conference on General PracticeCopenhagen, Denmark

May 13-16, 2009

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=ArgentinaAU=AustraliaBZ=BrazilCH=ChinaCN=CanadaFR=FranceGE=GermanyHU=HungaryIN=IndiaIS=IsraelIT=ItalyJA=JapanMA=MalaysiaME=Mexico

Starfield 11/06IC 3493 n

NE=NetherlandsPO=PolandRU=RussiaSA=South AfricaSI=SingaporeSK=South KoreaSP=SpainSW=SwedenSZ=SwitzerlandTK=TurkeyTW=TaiwanUK=United KingdomUS=United States

Country* Clusters: Health Professional Supply and Child Survival

Starfield 07/07HS 3754 nSource: Chen et al, Lancet 2004; 364:1984-90.

De

ns

ity

(w

ork

ers

pe

r 1

00

0)

Child mortality (under 5) per 1000 live births3 5 9 50 100 250

25

15

10

5.0

2.5

1

*186 countries

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 07/07PC 3755 n

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 07/07PC 3756 n

Why Is Primary Care Important?

Better health outcomes

Lower costs

Greater equity in health

Starfield 07/07PC 3757 n

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 03/08PC 3971 nSource: Starfield et al, Milbank Q 2005; 83:457-502.

Primary Care Scores, 1980s and 1990s

1980s 1990s

BelgiumFrance*

GermanyUnited States

0.8-

0.50.2

0.40.30.40.4

AustraliaCanadaJapan*

Sweden

1.11.2

-1.2

1.11.20.80.9

DenmarkFinland

NetherlandsSpain*

United Kingdom

1.51.51.5

-1.7

1.71.51.51.41.9

*Scores available only for the 1990s Starfield 07/07ICTC 3758 n

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 11/0202-405 sc

Starfield 11/02PC 2366 n

System Features Important to Primary Health Care

Starfield 11/06EQ 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

BelgiumFranceGermanyUS

0000

0010

0020

0000

AustraliaCanadaJapanSweden

1112

2222

2211

2211

DenmarkFinlandNetherlandsSpainUK

22222

22022

21222

22212

**

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 07/07GH 3794 n

Sources: Starfield & Shi, Health Policy 2002; 60:201-18. Gilson et al, Challenging Inequity through Health Systems (http://www.who.int/social_determinants/resources/csdh_media/hskn_final_2007_en.pdf; accessed March 17, 2009).

More Comprehensive Health Centres Have Better Vaccination Coveragea,b

Starfield 05/09COMP 4188

Source: World Health Organization. The World Health Report 2008: Primary Health Care – Now More than Ever. Geneva, Switzerland, 2008.

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 04/09PC 4180 n

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 04/09PC 4181

0123456789

101112

0 1 2 3 4 5 6 7 8 9 10 11 12 13

System Characteristics (Rank*)

Pra

ctic

e C

ha

ract

eri

stic

s (R

an

k*)

UK

NTH

SP

FIN CANAUS

SWE JAP

GER FRBEL

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 03/05ICTC 3099 n

0

0.5

1

1.5

2

1000 1500 2000 2500 3000 3500 4000

Per Capita Health Care Expenditures

Pri

ma

ry C

are

Sco

re

Primary Care Score vs. Health Care Expenditures, 1997

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

Starfield 11/06ICTC 3495 n

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. R2(within)=0.77.

Source: Macinko et al, Health Serv Res 2003; 38:831-65.

Year

High PC Countries*

Low PC Countries*

10000

PYLL

1970 1980 1990 2000

0

5000

Starfield 11/06IC 3496 n

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 07/07IC 3762 n

Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.

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 03/08GH 3992

Sources: IBRD/World Bank, April 8, 2008. King & Bertino, PLoS Negl Trop Dis 2008;2:e209.

Is Primary Care as important within

countries as it is among countries?

Starfield 07/07WC 3765 n

State Level Analysis:Primary Care and Life Expectancy

Source: Shi, Int J Health Serv 1994;24:431-58. Starfield 04/09WCUS 4178 n

71

72

73

74

75

76

77

78

4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5

Primary care physicians per 10,000 population

Life

exp

ecta

ncy

at b

irth

ME

NHVT

MA

RI

CT

NY

NJ

PA

OH

IN

IL

MI

WI

MN

IA

MO

ND

SD

NE

KSDE MDVA

WV NC

SC

GA

FL

KYTN

AL

MS

AR

LA

OK TX MT

ID

WY

CO

NMAZ

UT

NV

WAOR

CA

AK

HI

Primary Care and Infant Mortality Rates, Indonesia, 1996-2000

1996-19971997-1998

1998-1999 1999-2000

Primary care spendingper capita*

10.3 9.6 8.5 8.2

Hospital spendingper capita*

4.1 4.4 4.6 5.3

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 07/07WC 3796 n

Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004*

(n=455) Odds Ratio 95% CI**

Primary care score (0-5) 1.452 1.073, 1.966

Age (years) 0.969 0.957, 0.981

Chronic disease (yes/no) 0.578 0.360, 0.927

Recent illness (yes/no) 0.176 0.098, 0.316

Household wealth (scale 1-8) 1.219 1.007, 1.476

Completed primary school 0.733 0.374, 1.437

Clinic type (0=traditional; 1=PSF) 0.998 0.594, 1.679

*1= excellent/ good health; 0=bad/fair/poor health** standard errors adjusted for clustering by clinic

Starfield 07/07WC 3768 nSource: Macinko, Almeida, de Sá, Health Policy Plan 2007; 22:167-77.

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.

Marginal effect (% change in IMR with 10% increase in variable)-5 0 5 10 15

Hospital beds

Fertility rate

Clean water

PSF coverage

Illiteracy(women)

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

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 09/0404-167

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

Starfield 09/04WC 2957

What We Already Know

• Improving health (improving effectiveness)

• Keeping costs manageable (improving efficiency)

A primary care oriented system is important for

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Does primary care reduce inequity in

health?

Starfield 07/07EQ 3769 n

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.

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Percentage Reduction in Under-5 Mortality: Thailand, 1990-2000

Starfield 07/07WC 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:

1989 At least one primary care health center for each rural village

1993 Government medical welfare scheme: all children less than 12, elderly, disabled

2001 Entire adult population insured

Activities of Rural Doctors’ Society

Source: Vapattanawong et al, Lancet 2007; 369:850-5.

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 05/09PC 4184Source: Starfield et al, Milbank Q 2005;83:457-502.

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 05/09PC 4185Source: Starfield et al, Milbank Q 2005;83:457-502.

• 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 11/05IC 3326

• 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 09/0202-437 sc

Starfield 09/02PC 2218 n

ConclusionAlthough 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 11/05HS 3329

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

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Health Workforce

Starfield 10/07WF 3901

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 11/06SP 3499 n

Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.

Percentage of People Seeing at Least One Specialist in a Year

Starfield 01/07SP 3529 n

US 40% of total population; 54% of patients (users)

Canada(Ontario)

31% of population (68% at ages 65 and over)

UK about 15% of patients (at ages under 65)

Spain 30% 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.

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 09/07CMOS 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.

Percent of Patients Reporting Any Error by Number of Doctors Seen

in Past Two Years

Starfield 09/07IC 3870 nSource: Schoen et al, Health Affairs 2005; W5: 509-525.

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

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 12/05SP 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.

What is the right number of specialists?

What do specialists do?

What do specialists contribute to population health?

Starfield 01/06SP 3354

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 02/08PC 3966

ALL REQUIRE EVALUATION.

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 people’s health problems)

• Breadth of services

• Coordination (enhanced problems/needs recognition over time)

Starfield 06/08EVAL 4044

Good Primary Care Requires

• Health system POLICIES conducive to primary care practice

• Health services delivery that achieves the important FUNCTIONS of primary care

Starfield 06/08PC 4042

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.

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The Health Services System

Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.

Starfield 02/09HS 4133 n

LongevityComfortPerceived well-beingDiseaseAchievementRisksResilience

CAPACITY

PERFORMANCE

HEALTH STATUS(outcome)

Provisionof care

Receiptof care

PersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsKnowledge baseAccessibilityFinancingPopulation eligibleGovernance

People/practitioner interface

Cultural andbehavioral

characteristics

Social, political,economic, and

physical environments

Biologic endowmentand prior health

Problem recognitionDiagnosisManagementReassessment

UtilizationAcceptance and satisfactionUnderstandingParticipation

Community resources

PCAT(Primary Care Assessment Tool)

Starfield 05/0303-095

• First-contact (access and use)• Person-focused care over time• Comprehensiveness (services available

and provided)• Coordination

• Family centered• Community oriented• Culturally competent

Starfield 05/03PCM 2479

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 05/06WC 3421 n

0

1

2

3

4

5Access

Longitudinal

Gatekeeping

Comprehensive

CoordinationFamily focus

Community

Providers

Total Score

PSF (users) PSF (providers) PSF (managers)

First ContactResources Available

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 06/08PC 4046

Primary Care

Starfield 02/08EVAL 3968 n

First Contact • Accessibility• Use by people for each new problem

Longitudinal • Relationship between a facility and its population

• Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship

Comprehensive • Broad range of services• Recognition of situations where services are

needed

Coordination • Mechanism for achieving continuity• Recognition of problems that require follow-up

Structural and Process Elements of the Essential Features of Primary Care

Essential Features Performance

Utilization

Person-focused relationship

Capacity

Accessibility

Eligible population

Range of services

Continuity

First-contact

Longitudinality

Comprehensiveness

Coordination

Problem recognition

Starfield 199797-194

Starfield 04/97EVAL 1108 n

Structural and Process Elements of the Essential Features of Primary Care

Essential Features Performance

Utilization

Person-focused relationship

Capacity

Accessibility

Eligible population

Range of services

Continuity

First-contact

Longitudinality

Comprehensiveness

Coordination

Problem recognition

Starfield 10/08EVAL 4071 n

Welcome to the 16th Nordic Congress of General Practice