Comprehensiveness of Care: Concept and ImportanceBarbara Starfield, MDPresented at:RNZCGP Annual Quality SymposiumWellington, NZFebruary 14, 2009
Basic Coverage versus Comprehensive Primary CareStarfield 01/09COMP 4117Basic coverage: e.g., all ages, care by doctors, hospitals, prescription drugs, lab/diagnostic tests. (HEALTH SYSTEM responsibility)Comprehensive primary care: a range of services broad enough to care for all health needs except those too uncommon to maintain competence. (Who provides and Where)
What Is Comprehensiveness in Primary Care?Dealing with all health-related problems or interventions except those too uncommon to maintain competence(common = encountered in at least one per thousand patients in a year)Starfield 01/07COMP 3536
Comprehensiveness is the feature of primary care practice that is most salient in distinguishing primary care-oriented countries from other countries.Starfield 01/07COMP 3571
System Features Important to Primary Health CareStarfield 11/06EQ 3500 nSources: 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 SharingCompre-hensivenessBelgiumFranceGermanyUS0000001000200000AustraliaCanadaJapanSweden1112222222112211DenmarkFinlandNetherlandsSpainUK22222220222122222212
Criteria for ComprehensivenessStarfield 10/07COMP 3891In US studies: universal provision of extensive and uniform benefits for children, the elderly, women, and other adults; routine OB care; mental health needs addressed; minor surgery; generic preventive careIn European studies: treatment and follow-up of diseases (e.g., hypothyroidism, acute CVA, ulcerative colitis, work-related stress, n=17); technical procedures (e.g., wart removal, IUD insertion; removal of corneal rusty spot; joint injections); taking cervical smears; group health education; family planning and contraceptionSources: Starfield &Shi, Health Policy 2002; 60:201-18; Boerma et al, Br J Gen Pract 1997; 47:481-6; Boerma et al, Soc Sci Med 1998; 47:445-53.
Specialty services are more costly than primary care services, both from the systems viewpoint and from the viewpoint of individuals followed over time. This is especially the case for medical subspecialists. Sources: Starfield & Shi, Health Policy 2002; 60:201-18. Franks & Fiscella, J Fam Pract 1998; 47:105-9. Baicker & Chandra, Am Econ Rev 2004; 94:357-61. Starfield 05/06SP 3417
Although specialists usually do better at adhering to disease-oriented guidelines, generic outcomes of care (especially but not only patient-reported outcomes) are no better and are often worse than when care is provided by primary care physicians. Studies finding specialist care to be superior are more likely to be methodologically unsound, particularly regarding failure to adjust for case mix. Sources: Hartz & James, J Am Board Fam Med 2006; 19:291-302. Chin et al, Med Care 2000; 38:131-40. Donohoe, Arch Intern Med 1998; 158:1596-1608. Bertakis et al, Med Care 1998; 36:879-91. Harrold et al, J Gen Intern Med 1999; 14:499-511. Smetana et al, Arch Intern Med 2007; 167:10-20. Other studies reported in: Starfield et al, Milbank Q 2005; 83:457-502.Starfield 04/07SP 3700
Resource Use, Controlling for Morbidity Burden*More DIFFERENT specialists seen: higher total costs, medical costs, diagnostic tests and interventions, and types of medicationMore DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventionsMore 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.
The higher the ratio of medical specialists to population, the higher the surgery rates, performance of procedures, and expenditures.The higher the level of spending in geographic areas, the more people see specialists rather than primary care physicians.Quality of care, both for illnesses and preventive care, are no better in higher spending areas, and in most cases are worse.Sources: Welch et al, N Engl J Med 1993; 328:621-7. Fisher et al, Ann Intern Med 2003; 138:273-87. Baicker & Chandra. Health Aff 2004; W4(April 7):184-197 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf). Starfield 09/0404-145(Data controlled for sociodemographic characteristics, co-morbidity, and severity of illness)SP 2964Starfield 09/04SP 2964
Royal College of Physicians and SurgeonsTask Force to Review Fundamental Issues in Specialty EducationStarfield 01/09SP 4085
GENERALISMSPECIALISMKnowledgeBreadthDepthMultidisciplinarySingle disciplineUndifferentiatedDifferentiatedPrevention, investigation/ management/ rehabilitation and chronic careInvestigation/managementDisease is considered in the context of multiple systems and the whole.Disease is considered in the context of a single system.Community- and hospital-basedHospital-basedSkillsPredominantly non-invasivePredominantly invasiveAttitudesHolisticReductionist
Comprehensiveness is a critical feature of primary care because it is responsible for avoiding referrals for common needs in the population and hence for saving unnecessary expenditures.Comprehensiveness is measured by the availability in primary care of a wide range of services to meet common needs, and by demonstrating that care is, indeed, provided for a broad range of problems and needs.Starfield 09/08COMP 4065
Assessment of ComprehensivenessAssess the range of services available in primary care: diagnosis and management of all common problems in the population, mental health problems, minor surgery, indicated screening for disease, common minor procedures, common follow-up needs. (Normative measure)Determine the cumulative percentage contributed by visits for the most common problems. The higher the percentage, the greater the breadth of services provided. (Empirical measure) Starfield 01/07COMP 3538Sources: Rivo et al, JAMA 1994; 271:1499-1504. Boerma et al, Br J Gen Pract 1997; 47:481-6.
Comprehensiveness in Primary CareStarfield 03/08COMP 4008
Wart removalIUD insertionIUD removalPap smearSuturing lacerationsTympanocentesisRemoval of cystsVision screeningJoint aspiration/injectionForeign body removal (ear, nose)Setting of simple fracturesSprained ankle splintAge-appropriate surveillanceFamily planningImmunizationsSmoking counselingRemove ingrowing toenailHearing screeningBehavior/MH counselingHome visits as neededElectrocardiographyNutrition counselingExamination for dental statusOTHERS?
In New Zealand, Australia, and the US, an average of 1.4 problems (excluding visits for prevention) were managed in each visit. However, primary care physicians in the US managed a narrower range: 46 problems accounted for 75% of problems managed in primary care, as compared with 52 in Australia and 57 in New Zealand.Starfield 01/07COMP 3537Source: Bindman et al, BMJ 2007; 334:1261-6.
Assessment of Comprehensiveness May Differ from Place to PlaceComprehensiveness means that primary care meets all health-related needs of the population except those that are too uncommon to maintain competence. This will differ from place to place.Starfield 04/0404-047Starfield 04/04COMP 2817
Primary Care Oriented Health ServicesSource: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/08HS 4139 n
The Health Services System: ComprehensivenessSource: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 199999-014Starfield 1999HS 1441
PCAT: Comprehensiveness SubdomainsServices availableServices provided (received)Starfield 01/0202-022Starfield 01/02PCM 2047
Primary Care Domains and Subdomains: ComprehensivenessComprehensiveness: services availableAvailability of 11 specific services, e.g., family planning.Comprehensiveness: services providedServices received from the primary care source, e.g., discussions of ways to stay healthy.
Starfield 199696-24Starfield 05/96PCM 1017
PCAT: Comprehensiveness(Services Available*)Following is a list of services that you or your family might need at some time. For each one, please indicate whether it is available at your PCPs office.Family planning or birth control methodsCounseling for mental health problemsSewing up a cut that needs stitchesVision screeningStarfield 01/0202-027Starfield 01/02PCM 2052*Examples
PCAT: Comprehensiveness(Services Provided*)In visits to your PCP, are any of the following things discussed with you?Advice about healthy foods and unhealthy foodsWays to handle family conflicts that may arise from time to timeAdvice about appropriate exercise for youChecking on and discussing the medications you are takingStarfield 01/0202-028Starfield 01/02PCM 2053*Examples
Specialist societies are often strong enough to prevent primary care from providing services that are provided in primary care elsewhere and despite evidence that they can be provided safely in primary care.monitoring anticoagulant therapy in atrial fibrillationroutine colonoscopyearly voluntary abortion management of in