1. The Primacy of Primary Care in Health Services Systems Barbara Starfield, MD, MPH November 2002

2. The Countries, Mid-1990s Australia Belgium Canada Denmark Finland France Germany Japan Netherlands Spain Sweden United Kingdom United States Starfield

3. Reimbursement of Physicians ** 1980s1990s1980s1990s BelgiumFFFF FranceFFFF GermanyFFFF United StatesFFFF AustraliaFFFF CanadaFFFF JapanFFFF SwedenSSSS DenmarkC/FF/CS/FF Finland * S/CS/CSS NetherlandsC/FC/FFS SpainSSSS United KingdomCC/FSS Primary CareSpecialists Starfield 2000

4. Are Specialists Limited to Hospital Practice? Early-Mid 1990s Belgium France Germany United States No Australia Canada Japan Sweden No Denmark Finland Netherlands Spain United Kingdom Yes No Yes Starfield 2000

5. 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

6. Primary Care Orientation of Health Systems: Rating Criteria Practice Characteristics –First-Contact –Longitudinality –Comprehensiveness –Coordination –Family-centeredness –Community orientation Starfield Source: Starfield, 1998.

7. Primary Care Scores, 1980s and 1990s Belgium0.80.4 France* - 0.3 Germany0.50.4 United States0.20.4 Australia1.11.1 Canada1.21.2 Japan* - 0.8 Sweden1.20.9 Denmark1.51.7 Finland1.51.5 Netherlands1.51.5 Spain* - 1.4 United Kingdom1.71.9 1980s 1990s Starfield 10/02

8. System and Practice Characteristics Facilitating Primary Care, Early-Mid 1990s UK NTH SP FIN CAN AUS SWE JAP GER FR BEL US DK Starfield 11/00

9. Health Care Expenditures per Capita, 1996 Belgium France Germany United States ----- 1693 1978 2222 3708 Australia Canada Japan Sweden ----- 1776 2002 1581 1405 Denmark Finland Netherlands Spain United Kingdom ----- 1430 1389 1756 1131 1304 Starfield 2000

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

11. Primary Care Orientation and Population Health Status Starfield 10/02

12. Average Rankings* for Health Indicators in Infancy, for Countries Grouped by Primary Care Orientation 6.44.67.84.8 Highest (Denmark, Finland, Netherlands, Spain, UK**) 6.05.55.37.3 Middle (Australia, Canada, Japan, Sweden) 8.811.57.89.5 Lowest (Belgium, France, Germany, US) Infant Mortality (1996) Postneonatal Mortality (1993) Neonatal Mortality (1993) Low Birth Weight (1993) Starfield 04/01 5.96.75.06.2

13. Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation Starfield 2000 All Except SuicideSuicide All Except External Female 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 2.87.0 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.

14. Average Rankings* for Life Expectancy at Ages 40, 65, and 80, for Countries Grouped by Primary Care Orientation MaleFemaleMale Female MaleFemale 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**) 4.3 3.52.5Middle (Australia, Canada, Japan, Sweden) 6.98.09.5Lowest (Belgium, France, Germany, US) Starfield 04/01 6.75.96.6 6.87.1

15. Average Rankings for World Health Organization Health Indicators for Countries Grouped by Primary Care Orientation DALEs Child Survival Equity Overall Health Lowest (Belgium, France, Germany, US) 16.322.536.3 Middle* (Australia, Canada, Sweden, Japan) 4.816.526.0 Highest* (Denmark, Finland, Netherlands, Spain, UK) 16.015.231.6 DALE: Disability adjusted life expectancy (life lived in good health) Child survival: survival to age 2, with a disparities component Overall 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 11.029.115.8

16. Percentage of Individuals Who Smoke per Capita at Ages 15 and Older, Early-Mid 1990s* Belgium21.031.0 France20.038.0 Germany21.536.8 United States24.628.6 Australia23.828.2 Canada26.026.0 Japan13.360.4 Sweden26.625.2 Denmark40.145.9 Finland20.033.0 Netherlands30.542.9 Spain21.044.0 United Kingdom28.029.0 FemaleMale *All countries 1992, except Canada (1991), Spain (1993)

17. Ranking of Countries by Income Inequality Earned IncomeDisposable Income Country (90/20 ratio) (Gini) Belgium 5 3 France 10 8 Germany 7 6 United States 11 13 Australia 12 10 Canada 9 7 Japan 1 11 Sweden 2 2 Denmark 8 4 Finland 6 1 Netherlands 4 5 Spain 3 9 United Kingdom 13 12 Starfield 2000

18. 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

19. Primary Care Score and Health Outcomes Source: Macinko et al., 2002. Starfield 06/02

20. Primary Care Score and Premature Mortality in 18 OECD Countries Year Low PC Countries* High PC Countries* All Countries* 1970198019902000 0 5000 10000 PYLL Starfield 06/02 Source: Macinko et al., 2002.

21. 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

22. 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

23. Rates of Avoidable Adult Hospitalization for 6 Conditions and Family Physicians per 10,000 Population Source: Parchman & Culler, 1994. Starfield 10/02

24. Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians per 10,000 Population Starfield 10/02 Source: Parchman & Culler, 1994.

25. Physician Supply and Odds Ratios* of Diagnosis of Late-Stage Colorectal Cancer UrbanNon-urban Primary care physicians0.92**0.96 Specialty physicians1.12**1.02 Starfield 10/02 Source: Roetzheim et al., 1999. *change in odds of late stage diagnosis with each 10 percentile increase in supply of physicians **significant at p<.01

26. Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors* No. of Patients Adjusted with Complete Odds Ratio Risk FactorData ( 95% CI) P Value No primary care2044.4 (2.2-8.9) <0.001 No medical insurance 2042.2(1.0-4.6) 0.04 Noncompliance with antihypertensive1992.0 (1.5-2.7) <0.001 regimen† One or more alcohol-related problems204 2.2 (0.8-6.3) 0.14 Illicit drug use‡2041.3 (0.5-3.6) 0.60 †Categorized on a five-point scale. ‡In the past year. Source: Shea et al., 1992. Starfield 1999

27. 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

28. Primary Care Reform, 1984-90 to 1994-96 Percent Decline in Mortality - Various Causes, Barcelona, Spain E = 23 E = 40 M = 38 M = 35 L = 35 L = 6 0 5 10 15 20 25 30 35 40 45 Hypertension Perinatal % Decline E = Early Implementation M = Later Implementation L = Late Implementation Starfield 2000 Source: Villalbi et al., 1999.

29. 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

30. State Level Analysis: Primary Care and Life Expectancy PC physicians/population positively associated with longer life expectancy. Source: Shi et al., 1999. 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

31. Total Mortality Infant Mortality Income Inequality (Robin Hood Index) Primary Care Physicians Life Expectancy 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.

32. Total Mortality Neonatal Mortality Income Inequality (GINI COEFFICIENT) Primary Care Physicians 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 -.35**.42** Starfield Source: Shi et al., 1999.

33. Does Primary Care Reduce Disparities in Health across Population Subgroups? Starfield 10/02

34. 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 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 & Starfield, 2000. Starfield 2000

35. 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 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 2000 Based on data in Shi & Starfield, 2000.

36. 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 2000 Based on data in Shi & Starfield, 2000.

37. 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

38. 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

39. 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.