The Vision for Primary Care: Realizing, Renewing, and Supporting Barbara Starfield, MD, MPH San Francisco, California April 2006

Global Health Chart Starfield 10/ Source: Karolinska Institute: Starfield 09/04 IC 2941

Country* Clusters: Health Professional Supply and Child Survival Starfield 12/04 HS 3083 Source: Chen et al, Lancet 2004; 364: Density (workers per 1000) Child mortality (under 5) per 1000 live births *186 countries

Life Expectancy Compared with GDP per Capita for Selected Countries Source: Economist Intelligence Unit. Healthcare International. 4th quarter London, UK: Economist Intelligence Unit, Country codes: AG=Argentina AU=Australia BZ=Brazil CH=China CN=Canada FR=France GE=Germany HU=Hungary IN=India IS=Israel IT=Italy JA=Japan MA=Malaysia ME=Mexico Starfield 07/05 IC 3228 NE=Netherlands PO=Poland RU=Russia SA=South Africa SI=Singapore SK=South Korea SP=Spain SW=Sweden SZ=Switzerland TK=Turkey TW=Taiwan UK=United Kingdom US=United States

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. Starfield 09/ Starfield 09/04 PC 2943

Why Is Primary Care Important? Starfield 09/ Better health outcomes Lower costs Greater equity in health Starfield 09/04 PC 2945

Evidence of the Benefits of a Primary Care-Oriented Health System Starfield 09/ Starfield 09/04 PC 2946

Primary Care Scores, 1980s and 1990s 1980s1990s Belgium France* Germany United States Australia Canada Japan* Sweden Denmark Finland Netherlands Spain* United Kingdom Starfield 10/ *Scores available only for the 1990s Starfield 10/02 IC 2238

Primary Care Score vs. Health Care Expenditures, 1997 Starfield 10/ US NTH CAN AUS SWE JAP BELFR GER SP DK FIN UK Starfield 10/00 IC 1731

Primary Care Strength 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. R 2 (within)=0.77. Source: Macinko et al, Health Serv Res 2003; 38: Starfield 10/ Year High PC Countries* Low PC Countries* PYLL Starfield 09/04 IC 2953

Health in the US Relative* to 13 Other Large Industrialized Countries Starfield 03/05 IC 3125 Sources: OECD. Health at a Glance, WHO. World Health Report s2000 Life expectancy (LE) At birth13 At age Potential years of life lost*** Healthy life expectancy (HLE) At birth -12 At age Percentage of HLE -12 Cancer death rate**12 of 12 Cancer incidence 4 of 7 Ischemic heart disease death rate**10-11 of 12 *1 = best rank **age-adjusted ***at age 70

Is US Health Really the Best in the World? 13 th (last) for low-birth-weight percentages 13 th for neonatal mortality and infant mortality overall 11 th for postneonatal mortality 13 th for years of potential life lost (excluding external causes) 11 th for life expectancy at 1 year for females, 12 th for males 10 th for life expectancy at 15 years for females, 12 th for males 10 th for life expectancy at 40 years for females, 9 th for males 7 th for life expectancy at 65 years for females, 7 th for males 3 rd for life expectancy at 80 years for females, 3 rd for males 10 th for age-adjusted mortality In a comparison of 13 countries,* the US rankings were: Starfield 03/06 IC 3382 *Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States Source: Starfield, JAMA 2000; 284:483-5.

Community surveys in industrialized countries show that primary care oriented countries (Australia, Canada, New Zealand, United Kingdom) are rated higher than other countries (US and Germany) on many aspects of care, including view of the health care system as NOT needing complete rebuilding finding the regular physician’s advice helpful coordination of care The United States rates the poorest on ALL aspects of experienced care, including access, person-focused care over time, unnecessary tests, polypharmacy, adverse effects, and rating of medical care received. Source: Schoen et al, Health Aff 2005; W5: Starfield 11/05 IC 3325

An orientation to primary care reduces sociodemographic and socioeconomic disparities (inequities) in access to health services in population health Starfield 03/06 IC 3383

Of 21 OECD countries, the United States is, by far, the most socially inequitable (poor versus non-poor) in terms of the annual probability of visiting a physician. It is one of less than a handful of countries that does not collect information on visits to primary care physicians and specialists in population-based surveys. Starfield 03/06 IC 3384 Source: van Doorslaer et al, CMAJ 2006; 174:

Have more equitable resource distributions Have health insurance or services that are provided by the government Have little or no private health insurance Have no or low co-payments for health services Are rated as better by their populations Have primary care that includes a wider range of services and is family oriented Have better health at lower costs Overall, primary care oriented countries Sources: Starfield and Shi, Health Policy 2002; 60: van Doorslaer et al, Health Econ 2004; 13: Schoen et al, Health Aff 2005; W5: Starfield 11/05 IC 3326

Starfield 09/ Is Primary Care as Important within Countries as It Is among Countries? Starfield 09/04 WC 2955

Health Care Expenditures and Mortality 5 Year Followup: United States, 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, J Fam Pract 1998; 47: Starfield Starfield 05/99 WC 1504

Primary care physician supply is consistently associated with improved health outcomes (all-cause, cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, self-rated health). A 12% increase in such physicians (1 per 10,000) improves outcomes an average of 4% (range % depending on particular outcome and geographic unit of analysis). Starfield 06/05 WC 3217 Source: Macinko et al, mss 2005

In both England and the US, each additional primary care physician per 10,000 population (a 12-20% increase) is associated with a decrease in mortality of 3-10%, depending on the cause of death. This is true even after adjusting for sociodemographic and socioeconomic characteristics. Source: Gulliford, J Public Health Med 2002; 24:252-4, and personal communication 9/04. Starfield 03/05 WC 3102

Low Birth Weight among US Rural, Urban, and Primary Care Health Center Infants Source: Politzer et al, Med Care Res Rev 2001; 58: Starfield 10/ 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 Geographic area Racial composition Starfield 10/03 WC 2637

Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality, 50 US States, 1990 Areas with low income inequality (mostly homogeneous high income areas) High primary care resources 0.8% decrease in mortality Low primary care resources 1.9% increase in mortality Areas with high income inequality High primary care resources 17.1% decrease in mortality Low primary care resources 6.9% increase in mortality *compared with population mean Based on data in Shi et al, J Fam Pract 1999; 48: Starfield 05/05 EQ 3215

Reductions* in Inequality in Health by Primary Care: Stroke Mortality, 50 US States, 1990 Areas with low income inequality (mostly homogeneous high income areas) High primary care resources 1.3% decrease in mortality Low primary care resources 2.3% increase in mortality Areas with high income inequality High primary care resources 2.3% decrease in mortality Low primary care resources 1.1% increase in mortality *compared with population mean Starfield 05/05 EQ 3213 Based on data in Shi et al, J Fam Pract 1999; 48:

Reductions in Inequality in Health by Primary Care: Self-Reported Health, 60 US Communities, 1996 Areas with low income inequality (mostly homogeneous high income areas) –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* Percent reporting fair or poor health Starfield 08/ Based on data in Shi & Starfield, Int J Health Serv 2000; 30: *compared with median # of primary care physicians to population ratios Starfield 08/02 EQ 2181

Source: Shi et al, Soc Sci Med 2005; 61(1): In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population. The association of primary care with decreased mortality is greater in the African-American population than in the white population. Starfield 06/05 WC 3216

25% of US physicians are trained outside the US. Most notably, those countries that contribute to maintaining the PRIMARY CARE (but not specialist) physician supply in the US are those countries that rate particularly poor in health and are particularly deprived of health professionals. Starfield 03/06 WF 3385 Source: Starfield B, Fryer GE Jr., 2006

Primary Care and Specialty Care Starfield 08/05 GS 3290

The Regional Primary Care and Specialty Physician Supply and Odds of Late-stage Diagnosis of Colorectal Cancer Source: Roetzheim et al, J Fam Pract 1999; 48: Starfield 08/ Primary CareSpecialists Percentiles Odds Ratios Starfield 08/02 WC 2179

Early detection of breast cancer is greater when the supply of primary care physicians is higher. Each tenth percentile increase in primary care physician supply is associated with a statistically significant 4% increase in the likelihood of EARLY (rather than late) stage diagnosis. Starfield 09/ Source: Ferrante et al, J Am Board Fam Pract 2000; 13: Starfield 09/04 WC 2960

For cervical cancer, rates of incidence of advanced stage presentation are lower in areas that are well-supplied with family physicians, but there is no advantage of having a greater supply of specialist physicians, either in total or for obstetrician/gynecologists. Starfield 09/ Source: Campbell et al, Fam Med 2003; 35:60-4. Starfield 09/04 WC 2961

Melanoma is identified at an earlier stage in areas where the supply of family physicians is high, both in urban areas and non-urban areas. The same is the case for dermatologists, but the relationship is not statistically significant, and there is no relationship of early detection with the supply of other specialists. Starfield 10/ Source: Roetzheim et al, J Am Acad Dermatol 2000; 43: Starfield 09/04 WC 2962

The variation in numbers (per population) of neonatologists does not vary with measures of need (very low birth weight ratios); there is no relationship between the supply of neonatal resources and infant mortality, and increases in the supply of neonatologists beyond a moderate level confer no additional benefit. Starfield 10/ Source: Goodman et al, N Engl J Med 2002; 346: Starfield 09/04 SP 2959

There are large variations in both costs of care and in frequency of interventions. Areas with high use of resources and greater supply of specialists have NEITHER better quality of care NOR better results from care. Starfield 12/05 SP 3343 Sources: Fisher et al, Ann Intern Med 2003; Part 1: 138:273-87; Part 2: 138: Baicker & Chandra, Health Aff 2004; W4: Wennberg et al, Health Aff 2005; W5:

Above a certain level of specialist supply, the more specialists per population, the worse the outcomes. In 35 analyses dealing with differences between types of areas (7) and 5 rates of mortality (total, heart, cancer, stroke, infant), the greater the primary care physician supply, the lower the mortality for 28. The higher the specialist ratio, the higher the mortality in 25. Controlled only for income inequality Source: Shi et al, J Am Board Fam Pract 2003; 16: Starfield 08/05 SP 3256

What is the right number of specialists? What do specialists do? Starfield 01/06 SP 3354

Percentage of Patients* Referred in a Year Starfield 02/ United States % Mid-Atlantic HMO30.0 Midwestern HMO35.7 Midwestern POS34.9 Northeastern POS32.6 Lower mid-Atlantic POS36.8 United Kingdom GP Research Database13.9 Source: Forrest et al, BMJ 2002; 325: *Case-mix adjusted Starfield 02/03 GS 2422

Percentage of Patients, from Birth to Age 17, Referred in a Year United States % Mid-Atlantic HMO18.6 Midwestern HMO28.8 Midwestern POS25.7 Northeastern POS21.1 Lower mid-Atlantic POS22.9 United Kingdom GP Research Database 8.7 Source: Forrest et al, Arch Pediatr Adolesc Med 2003; 157: Starfield 03/05 GS 3113

What Is the Appropriate Role for Primary Care and Specialist Physicians? Starfield 12/04 GS 3079 Primary care: person-focused care over time, first- contact access, ongoing care of all but uncommon problems, coordination of care Specialist care: Short-term consultation for diagnosis or initiation of management Recurrent consultation for advice on continuing management Long-term referral for management of unusual conditions

Starfield 07/ Source: Starfield et al, J Am Board Fam Pract 2002; 15: About half of all referrals are for short-term consultation. For the remaining half, the overwhelming expectation is for shared care rather than transferred care. Starfield 07/03 GS 2518

Children All agesunder age 15 All physicians 14 7 Family practice 3 2 Internal medicine 8 25 Pediatrics 3 2 Other specialties Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, *for this visit Starfield Percent of Visits Made by Patients Who Were Referred*: US, 1994 Starfield 10/00 GS 1751

Could it be that 65-75% of visits to specialists are for routine follow-up? Does this seem like a rational use of expensive and potentially dangerous use of resources? Starfield 01/06 SP 3355

Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Starfield 01/06 IC 3352 Source: Schoen et al, Health Affairs 2005; W5: CountryOne doctor4 or more doctors Australia1237 Canada1540 Germany1431 New Zealand1435 UK1228 US2249

Association of Regional Quality of Care for Acute Myocardial Infarction (AMI) and Average Number of Physicians per AMI Patient (Quartiles) with Changes in Survival and Spending, Starfield 03/06 QC 3391 Source: Skinner et al, Health Aff 2006; W6:W23-W47.

Monthly Prevalence Estimates of Illness in the Community and the Roles of Physicians, Hospitals, and University Medical Centers in the Provision of Medical Care Starfield 10/05 GS 3321 Source: White et al, N Engl J Med 1961; 265: Adult population at risk Adults reporting one or more illnesses or injuries per month Adults consulting a physician one or more times per month 9 adult patients admitted to a hospital per month 5 adult patients referred to another physician per month 1 adult patient referred to a university medical center per month

Results of a Reanalysis of the Monthly Prevalence of Illness in the Community and the Roles of Various Sources of Health Care Starfield 12/05 GS 3345 Source: Green et al, N Engl J Med 2001; 344: persons 800 report symptoms 327 consider seeking medical care 217 visit a physician’s office (113 visit a primary care physician’s office) 65 visit a complementary or alternative medical care provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency department 8 are hospitalized <1 is hospitalized in an academic medical center

Participation in Medical and Dental Care in a Typical Month for 1000 Children and Adolescents Aged 0 to 17 years (A), and 1000 adults >=18 years (B) A. Children aged 0-17 yearsB. Adults >= 18 years Starfield 02/01 GS visit a physician’s office 82 visit a dentist’s office 13 visit an emergency department 8 visit a hospital outpatient clinic 3 are hospitalized 2 receive home health care 235 visit a physician’s office 73 visit a dentist’s office 13 visit an emergency department 26 visit a hospital outpatient clinic 10 are hospitalized 18 receive home health care Source: Dovey et al, Pediatrics 2003; 111:

The positive predictive value of rectal bleeding for colorectal cancer is less than 1 in 1000 in the community, 1 in 50 in general practice, and 1 in 3 of those referred to hospital by GPs. Starfield 10/05 D 3322 Source: Fijten et al, Br J Gen Pract 1994; 44(384):320-5.

What We Need to Know What specialists contribute to population health The optimum ratio of specialists to population The functions of specialty care and the appropriate balance among the functions The appropriate division of effort between primary care and specialty care The point at which an increasing supply of specialists becomes dysfunctional Starfield 11/05 SP 3328

PC Challenges and opportunities –Contributing to improving health systems through Strengthening of primary care Strengthening the relationship between primary care, secondary care (diagnostic and management support), and tertiary care (unusual or unusually complex health problems) –Contributing to knowledge in the areas of The impact of multi-morbidity on assessment of the quality of health services Reductions in adverse effects of health services through better integration of services 2.Imperatives –Residency training in the community, not in the hospital –Advocacy for primary care at the national and international levels, based on a unified strategy combining the forces of all primary care specialties Starfield 03/06 PC 3395