1. Primary Care Versus Specialist Physician Supply

2. 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.

3. The Regional Primary Care and Specialty Physician Supply and Odds of Late-stage Diagnosis of Colorectal Cancer Primary CareSpecialists Percentiles 102030405060708090100 1.6 1.4 1.2 1 0.8 0.6 0.2 0 0.4 Odds Ratios

4. 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.

5. 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.

6. 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.

7. Patients receiving care from specialists providing care outside their area of specialization have higher mortality rates for community-acquired pneumonia, acute myocardial infarction, congestive heart failure, and upper gastrointestinal hemorrhage.

8. 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 birth weight 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 birth weight, lower life span Note: All variables are ecologic, not individual. *Overall mortality; mortality from heart disease, mortality from cancer, neonatal mortality, life span, low birth weight.

9. 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. (Data controlled for sociodemographic characteristics, co-morbidity, and severity of illness)

10. We know that 1.Inappropriate referral to specialists leads to greater frequency of tests than appropriate referrals to specialists. 2.Inappropriate referrals to specialists leads to poorer outcomes than appropriate referrals. 3.The socially advantaged have higher rates of visits to specialists than the socially disadvantaged. 4.Although greater primary care physician supply is associated with better health in populations, greater specialist supply is not generally associated with better health outcomes.

11. Does Primary Care Reduce Inequity in Health?

12. Equity in health is the absence of systematic and potentially remediable differences in one or more aspects of health across population groups defined geographically, demographically, or socially.

13. In state-level analyses controlled for demographic and socioeconomic variables, a 20% increase in the supply of primary care physicians (one more per 10,000) is associated with a 3.3% lower age-adjusted mortality rate among African-American population 2.0% lower age-adjusted mortality rate among white population That is, greater primary care resources are even more beneficial to disadvantaged (African- American) populations than to the majority (white) population.

14. Low Birth Weight among US Rural, Urban, and Primary Care Health Center Infants 8.8 7.5 6.8 6.0 13.6 10.4 13.0 7.4 US urban infants Urban health center 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 14.00.012.010.02.04.06.08.0 Geographic area Racial composition

15. Association of Primary Care with Reduced Racial Disparities in Healthy Life.8622.7614.8260 *. 7658.8423.7978.7805. 8693 * 0.70 0.72 0.74 0.76 0.78 0.80 0.82 0.84 0.86 0.88 CHCNHIS WhiteBlackHispanicOther Fraction of Healthy Life * * * *P<.05 Health Center patients experience lower levels of healthy life across all racial/ethnic groups. Significant racial/ethnic disparities exist in the nation’s low-income individuals*. Health Center Hispanic patients experience greater healthy life, no Black/White differences. *people under poverty level with at least one doctor visit

16. Odds Ratios for Poor Mental Health Status by Adequacy of Primary Care in Different Population Groups, US, 1998-1999

17. Odds Ratios for Poor Physical Health Status by Adequacy of Primary Care, in Different Population Groups, US, 1998-1999

18. 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

19. 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

20. 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* *compared with median # of primary care physicians to population ratios Percent reporting fair or poor health

21. Total Mortality Infant Mortality Income Inequality (Robin Hood Index) Primary Care Physicians Life Expectancy Low Birth Weight.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) *p<.05; **p<.01.

22. Primary Care Reform, 1984-90 to 1994-96, Percent Decline in Mortality - Various Causes, Barcelona, Spain E = 23 E = 40 M = 38 M = 35L = 35 L = 6 0 5 10 15 20 25 30 35 40 45 HypertensionPerinatal % Decline E = Early Implementation M = Later Implementation L = Late Implementation

23. Does Primary Care Reduce Inequity in Health in Developing Countries? So far, the evidence for the benefits of primary care has come from industrialized countries. What about developing countries? Although there have been very few studies of this subject in developing countries, the conclusion is the same: better primary health care, more equity in health services and health outcomes.

24. In 7 African countries The highest 1/5 of the population receives well over twice as much financial benefit from overall government health spending (30% vs 12%). For primary care, the poor/rich benefit ratio is much lower (23% vs 15%). “From an equity perspective, primary care represents a clear step in the right direction.”

25. Impact of a Primary Care Oriented Approach in Bolivia, Early 1990s Reformed Areas Adjacent Areas (Comparison) National Data Vaccinations complete78%8%21% 3+ growth monitorings80%8%NA Age-specific mortality Infant75117116* 1 year1958NA 2-4 years411NA 1-4 years72216* * Rates for children whose mothers have less than 5 years of education

26. Share of Public Spending on Health among Countries with Similar GNP per Capita But Very Disparate Child Survival (to Age 5) Rates, 1995 Ratio*: percent of expenditures for health from the government to poorest 20% vs. richest 20% of population High child survivalLow child survival Additional children lost per 1000 Sri Lanka1.1Ivory Coast0.3 150 Malaysia2.6Brazil0.4 45 Costa Rica2.1South Africa0.9 55 Jamaica3.3Ecuador0.2 25 Nicaragua1.0India0.3 50 Egypt0.6Ivory Coast0.3 100 *Ratios of one or more signify a greater share of government expenditures to poorest segment of population.

27. 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 and Health: Evidence-Based Summary

28. Conclusion (1) Virchow said that medicine is a social science and politics is medicine on a grand scale. We now know that it is primary health care that is responsible for improved health and for more equitable distributions of health. Along with improved social and environmental conditions as a result of public health and social policies, primary care is an important aspect of policy to achieve effectiveness, efficacy, and equity in health services.

29. Conclusion (2) Although socioeconomic factors undoubtedly influence health, health services are a highly policy-relevant influence because their effect is clear and relatively rapid, particularly concerning prevention of the progression of illness and effects of injury, especially at younger ages.