The Primacy of Primary Care in Health Services Systems

Barbara Starfield, MD, MPH

November 2002

The Countries, Mid-1990s

AustraliaBelgiumCanada

DenmarkFinlandFrance

GermanyJapan

NetherlandsSpain

SwedenUnited Kingdom

United StatesStarfield

Reimbursement of Physicians**

1980s 1990s 1980s 1990sBelgium F F F F

France F F F FGermany F F F F

United States F F F F

Australia F F F FCanada F F F F

Japan F F F FSweden S S S S

Denmark C/F F/C S/F FFinland* S/C S/C S S

Netherlands C/F C/F F SSpain S S S S

United Kingdom C C/F S S

Primary Care Specialists

Starfield 2000

Are Specialists Limited to Hospital Practice?Early-Mid 1990s

BelgiumFrance

GermanyUnited States

NoNoNoNo

AustraliaCanada

JapanSweden

NoNoNoNo

DenmarkFinland

NetherlandsSpain

United Kingdom

YesYesYesNoYes

Starfield 2000

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 0.4France* - 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 1.5 Spain* - 1.4United Kingdom 1.7 1.9

1980s 1990s

Starfield 10/02

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

rePrimary Care Score vs. Health Care

Expenditures, 1997

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

Primary Care Orientationand

Population Health Status

Starfield 10/02

Average Rankings* for Health Indicators in Infancy, for Countries Grouped by

Primary Care Orientation

6.44.67.84.8Highest

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

6.05.55.37.3Middle

(Australia, Canada, Japan, Sweden)

8.811.57.89.5Lowest

(Belgium, France, Germany, US)

Infant Mortality (1996)

Postneonatal Mortality (1993)

Neonatal Mortality (1993)

Low Birth Weight (1993)

Starfield 04/01

5.9 6.7 5.0 6.2

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 Life Expectancy at Ages 40, 65, and 80, for Countries

Grouped by Primary Care Orientation

MaleFemaleMaleFemaleMaleFemale

9.5

3.6

7.4

Age 80

8.8

3.8

8.0

Age 65

8.8

4.0

7.8

Age 40

9.39.08.6Highest(Denmark, Finland, Netherlands, Spain, UK**)

4.33.52.5Middle(Australia, Canada, Japan, Sweden)

6.98.09.5Lowest(Belgium, France, Germany, US)

Starfield 04/01

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

Lowest (Belgium, France, Germany, US)

16.3 22.5 36.3

Middle* (Australia, Canada, Sweden, Japan)

4.8 16.5 26.0

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

16.0 15.2 31.6

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

Source: Calculated from WHO, 2000.

Starfield 10/02

11.0 29.115.8

Percentage of Individuals Who Smoke per Capita at Ages 15 and Older, Early-Mid 1990s*

Belgium 21.0 31.0France 20.0 38.0Germany 21.5 36.8United States 24.6 28.6

Australia 23.8 28.2Canada 26.0 26.0Japan 13.3 60.4Sweden 26.6 25.2

Denmark 40.1 45.9Finland 20.0 33.0Netherlands 30.5 42.9Spain 21.0 44.0United Kingdom 28.0 29.0

Female Male

*All countries 1992, except Canada (1991), Spain (1993)

Ranking of Countries by Income Inequality

Earned Income Disposable IncomeCountry (90/20 ratio) (Gini)Belgium 5 3France 10 8Germany 7 6United States 11 13

Australia 12 10Canada 9 7Japan 1 11Sweden 2 2

Denmark 8 4Finland 6 1Netherlands 4 5Spain 3 9United Kingdom 13 12 Starfield 2000

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

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)

Source: Macinko et al., 2002. Starfield 06/02

Primary Care Score and Premature Mortality in 18 OECD Countries

Year

Low PC Countries*

High PC Countries* All Countries*

1970 1980 1990 20000

5000

10000

PYLL

Starfield 06/02Source: Macinko et al., 2002.

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 2000

Factors Related to In-hospital Standardized Mortality, England (NHS Hospitals),

1991-2 to 1994-5

Regression Coefficient

% of cases admitted as emergency 0.58

# hospital doctors/100 hospital beds -0.47

# GPs/100,000 population -0.67

Standardized admission ratio -0.15

% live discharges to home 1.61

% patients with co-morbidity 1.51

NHS facilities/100,000 population -1.12

Source: Jarman et al., 1999. Starfield 2000

Rates of Avoidable Adult Hospitalizationfor 6 Conditions and Family Physicians

per 10,000 Population

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

Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians

per 10,000 Population

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

Physician Supply and Odds Ratios*of Diagnosis of Late-Stage

Colorectal Cancer

Urban Non-urban

Primary care physicians 0.92** 0.96

Specialty physicians 1.12** 1.02

Starfield 10/02Source: Roetzheim et al., 1999.

*change in odds of late stage diagnosis with each 10 percentile increase in supply of physicians

**significant at p<.01

Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors*

No. of Patients Adjustedwith Complete Odds Ratio

Risk Factor Data (95% CI) P Value

No primary care 204 4.4 (2.2-8.9) <0.001No medical insurance 204 2.2(1.0-4.6) 0.04Noncompliance with antihypertensive 199 2.0 (1.5-2.7) <0.001 regimen† One or more alcohol-related problems 204 2.2 (0.8-6.3) 0.14Illicit drug use‡ 204 1.3 (0.5-3.6) 0.60

†Categorized on a five-point scale.‡In the past year.

•

Source: Shea et al., 1992. Starfield 1999

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)

Source: Franks & Fiscella, 1998. Starfield 1999

Primary Care Reform, 1984-90 to 1994-96Percent Decline in Mortality - Various Causes, Barcelona, Spain

E = 23

E = 40 M = 38M = 35 L = 35

L = 6

05

1015

20

253035

4045

Hypertension Perinatal

% D

eclin

e

E = Early ImplementationM = Later ImplementationL = Late Implementation

Starfield 2000Source: Villalbi et al., 1999.

Major Determinants of Outcomes*:50 US States

Specialty Physicians: More: all outcomes worse

Primary Care Physicians: Fewer: all outcomes worse

Hospital Beds: More: higher total, heart disease,

and neonatal mortality

Education: No relationship

Income: Lower: higher heart and cancer mortality

Unemployment: Higher: higher total mortality, lower life span,

more low birthweight

Urban: Lower mortality (all), longer life span

Pollution:Higher total mortality

Life Style: Worse: higher total and cancer mortality,

lower life span

Minority: Higher total mortality, neonatal mortality, low birthweight, lower life span

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

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xp

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

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. HI.MN

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.IL

.VA

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FL

.MT

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ME.NH

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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.

Does Primary Care Reduce Disparities in Health across

Population Subgroups?

Starfield 10/02

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

Reductions* in Inequality in Health by Primary Care: Stroke Mortality,

50 US States, 1990

Areas with low income inequality

High primary care resources 1.3% decrease in mortalityLow primary care resources 2.3% increase in mortality

Areas with high income inequality

High primary care resources 2.3% decrease in mortalityLow primary care resources 1.1% increase in mortality

*compared with population mean

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

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

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

• 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 Practice Characteristics: Evidence-Based Summary

Starfield 1999

• 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 Practice Characteristics: Evidence-Based Summary

Starfield 1999

Conclusions

Both international comparisons and studies within countries document the beneficial impact of primary care on effectiveness (health outcomes), on efficiency (lower costs), and on equity of health outcomes (reducing disparities across population subgroups).

Health policy should be directed toward strengthening the primary care orientation of health systems.