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
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SC.
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NC
.KY
.KS
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. ID
.MI
.TX
.IA
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NY
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.ND
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FL
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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.