primary care, health, and equity barbara starfield, md, mph supercourse lecture september 2004

Primary Care, Health, and Equity

Barbara Starfield, MD, MPH

Supercourse lecture

September 2004

Health systems have several major components:

• Public health activities

• Primary care

• Specialty care

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.

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.

Why Is Primary Care Important?

Better health outcomes

Lower costs

Greater equity in health

Evidence of the Benefits of a Primary Care-Oriented Health

System

Primary Care Scores, 1980s and 1990s1980s 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

System and Practice CharacteristicsFacilitating Primary Care, Early-Mid 1990s

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.

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

Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.

Average Rankings* for Health Indicators in Infancy, for Countries

Grouped by Primary Care Orientation

Low Birth Weight (1993)

Neonatal Mortality (1993)

Postneonatal Mortality (1993)

Infant Mortality (1996)

Worse primary care (Belgium, France, Germany, US)

9.5 7.8 11.5 8.8

Better primary care (Australia, Canada, Japan, Sweden, Denmark, Finland, Netherlands, Spain, UK**)

5.9 6.7 5.0 6.2

*Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance.**England and Wales only

Average Rankings* for YPLL in Countries Grouped by Primary Care Orientation

5.46.26.36.9Better primary care (Australia, Canada, Japan, Sweden, Denmark, Finland, Netherlands, Spain, UK**)

10.88.88.37.3Worse primary care (Belgium, France, Germany, US)

MaleFemaleMaleFemale

All Except ExternalSuicide


Average Rankings* for Life Expectancy at Ages 40, 65, and 80, for Countries Grouped by Primary Care Orientation

Age 40 Age 65 Age 80

Female Male Female Male Female Male


7.8 9.5 8.0 8.0 7.4 6.9

Better primary care (Australia, Canada, Japan, Sweden, Denmark, Finland, Netherlands, Spain, UK**)

6.7 5.9 6.6 6.6 6.8 7.1


Average Rankings for World Health OrganizationHealth Indicators for Countries Grouped

by Primary Care Orientation

DALEsChild Survival

Equity Overall Health


16.3 22.5 36.3

Better primary care (Australia, Canada, Sweden, Japan, Denmark, Finland, Netherlands, Spain, UK)

11.0 15.8 29.1

DALE: Disability adjusted life expectancy (life lived in good health)Child survival: survival to age 2, with a disparities componentOverall health: DALE minus DALE in absence of a health system Maximum DALE for health expenditures minus same in absence of a health system

Primary Care Score and Health Outcomes

Association with Primary Care Score*

Health Outcome In Males In Females

All-cause mortality

Life expectancy

Infant Mortality Rate

PYLL (all causes)

PYLL (pneumonia & influenza)

PYLL (asthma & bronchitis)

PYLL (cerebrovascular disease)

PYLL (heart disease)

*Primary care coefficient significant at p<0.05 level and 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) averaged from to .36 to .84.

Primary Care Score 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.

Year

Low PC Countries*

High PC Countries* All Countries*

1970 1980 1990 20000

5000

10000

PYLL

• Are primary care-oriented

• Have more equitable resource distributions

• Have government-provided health services or health insurance

• Have little or no private health insurance

• Have no or low co-payments for health services

Overall, countries that achieve better health levels

Is Primary Care as Important within Countries as It Is

among Countries?

State Level Analysis:Primary Care and Life Expectancy

71

72

73

74

75

76

77

78

4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50

Primary Care Physicians/10,000 Population

Life

Exp

ecta

ncy

. LA

SC.

.GA

.NV

.MS

.AL

.WV

.DE .

NC

.KY

.KS

.TN

. ID

.MI

.TX

.IA

.UT .

NY

.CA

.MD

.ND

.WI

.NM

.AZ

.NE

.MA

. CT

. HI.MN

.AK

.IL

.VA

.PA

.

FL

.MT

.OR

.NJ

ME.NH

.SD

.ID

.AR

.

.WA

.RI

R=.54

P<.05

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

In England, each additional primary care physician per 1000

(about a 20% increase) is associated with a decrease in

mortality of about 5%, adjusting for limiting long-term illness and

for various demographic and socioeconomic characteristics.

Regression Analysis: Characteristics of Medicare Beneficiaries in Fair or Poor

Health with a Preventable Hospitalization*

CharacteristicsOdds Ratio

(95% confidence interval)

Male

Primary care shortage area

1.31 (1.03-1.68)

1.70 (1.09-2.65)

*Only significant (p<.05) shown. Nonsignificant: age, nonwhite, education, marital status, income, supplemental insurance.

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)

Many other studies done WITHIN countries, both industrial 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.

primary care, health, and equity barbara starfield, md, mph supercourse lecture september 2004

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