starfield. benefits of primary care: evidence from international comparisons of 13 industrialized...

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, 1998. Starfield

Primary Care Orientation of Health Systems: Rating Criteria

• Practice Characteristics– First-Contact – Longitudinality – Comprehensiveness – Coordination – Family-centeredness – Community orientation

StarfieldSource: Starfield, 1998.

Primary Care Scores, 1980s and 1990s

Belgium 0.8 0.4 France - 0.3

Germany 0.5 0.4United States 0.2 0.4

Australia 1.1 1.1Canada 1.2 1.2

Japan - 0.8Sweden 1.2 0.9

Denmark 1.5 1.7Finland 1.5 1.5

Netherlands 1.5 1.5Spain - 1.4

United Kingdom 1.7 1.9

1980s 1990s

Starfield 2000

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*)

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

UK

NTH

SP

FIN CANAUS

SWE JAP

GER FRBEL

US

DK

Starfield 11/00

Health Care Expenditures per Capita, 1996

BelgiumFrance

GermanyUnited States

--------------------

1693197822223708

AustraliaCanada

JapanSweden

--------------------

1776200215811405

DenmarkFinland

NetherlandsSpain

United Kingdom

-------------------------

14301389175611311304 Starfield 2000

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

Starfield 10/00

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

International Comparisons:Birth Outcomes and Primary Care Score

9.5

11.5

7.3

5.54.8 4.6

0

2

4

6

8

10

12

14

Low BirthWeight Post NeonatalMortality

R= -.38 NS

Ave

rage

Ran

king

s

Low Med High

Source: Starfield & Shi, 2002.

Primary Care Score

Low: BEL, FR, GER, USMed: AUS, CAN, JAP, SWEHigh: DEN, FIN, NTH, SP, UK

R= -.74; p<.001

Starfield 09/02

Countries with weak primary care infrastructures have poorer health performance.

Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation

Starfield 2000

All Except Suicide Suicide All Except ExternalFemale Male Female Male Female Male

Lowest 9.5 10.8 7.3 8.3 8.8 10.8 (Belgium, France, Germany, US)

Middle 3.8 2.8 7.0 7.3 3.8 3.5 (Australia, Canada, Japan, Sweden)

Highest 7.6 7.4 6.8 5.8 8.2 7.0 (Denmark, Finland, Netherlands, Spain, UK)

Source: OECD, 1998.

Average Rankings for World Health OrganizationHealth Indicators for Countries Grouped

by Primary Care Orientation

31.615.216.0Highest* (Denmark, Finland, Netherlands, Spain, UK)

26.016.5 4.8Middle* (Australia, Canada, Sweden, Japan)

36.322.516.3Lowest (Belgium, France, Germany, US)

Overall Health

Child Survival Equity DALEs

Source: Calculated from WHO, 2000.Starfield 10/02

11.0 29.115.8

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

Starfield 10/02Source: Parchman & Culler, 1994.

State Level Analysis:Primary Care and Life Expectancy

PC physicians/population positively associated with longer life expectancy.

Source: Shi et al., 1999.

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

Lif

e E

xpec

tan

cy

.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

Starfield 03/02

TotalMortality

InfantMortality

Income Inequality(Robin Hood Index)

Primary CarePhysicians

LifeExpectancy

Low Birthweight

.41** -.17

-.29*

-.33*

.58**-.37**

.42** .35*

-.36**

Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990

Starfield*p<.05; **p<.01.Source: Shi et al., 1999.

TotalMortality

NeonatalMortality

Income Inequality(GINI COEFFICIENT)

Primary CarePhysicians

Stroke Mortality

Postneonatal Mortality

-.38** -.33*

-.18

-.33*

.18.16

.39** .40**

-.38**

Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990

*p<.05; **p<.01.

Life Expectancy

Life Expectancy

-.35**

.42**

StarfieldSource: Shi et al., 1999.

Reductions in Inequality in Health by Primary Care: Self-Reported Health,

60 US Communities, 1996Percent 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

Starfield 2000Based on data in Shi & 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 0.8% decrease in mortalityLow primary care resources 1.9% increase in mortality

Areas with high income inequality

High primary care resources 17.1% decrease in mortalityLow primary care resources 6.9% increase in mortality

*compared with population mean

Based on data in Shi & Starfield, 2000. Starfield 2000

Low Birthweight among US Rural, Urban, and Health Center Infants

Source: Politzer et al., 2001. Starfield 09/02

8.8

7.5

6.8

6.0

13.6

10.4

13.0

7.4

US urban infants

Urban health center infants infants

US rural infants

Rural health center infants

African American urban infants

African American urban health center infants

African American rural infants

African American rural health center infants

14.00.0 12.010.02.0 4.0 6.0 8.0

Geo

grap

hic

area

Rac

ial c

ompo

sitio

n

• 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

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

Primary Care and Equity: Evidence-Based Summary

starfield. benefits of primary care: evidence from international comparisons of 13 industrialized...

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