1. 4/19/2017
Although wealthy nations have better child survival, there is enormous variation in child survival at any given level of national wealth. Child survival (to age 5) in the US is lower than in other countries with comparable wealth. It is possible that this variability is associated, at least in part, by the way in which the health systems of the countries are oriented towards equitable distribution of health services.
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2. 4/19/2017
Benefits of Primary Care: Evidence from International Comparisons of 13 Industrialized Countries
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3. The Countries, Mid-1990s Australia (AUS) Belgium (BEL) Canada (CAN)
4/19/2017
The Countries, Mid-1990s
Australia (AUS)
Belgium (BEL)
Canada (CAN)
Denmark (DK)
Finland (FIN)
France (FR)
Germany (GER)
Japan (JAP)
Netherlands (NTH)
Spain (SP)
Sweden (SWE)
United Kingdom (UK)
United States (US)
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4. Primary Care Orientation of Health Systems: Rating Criteria
4/19/2017
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
Each country was rated (scores of 0, 1, or 2) on the strength of 9 characteristics of health policy that are conducive to strong primary care.
Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.
Source: Starfield, 1998.
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5. Primary Care Orientation of Health Systems: Rating Criteria
4/19/2017
Primary Care Orientation of Health Systems: Rating Criteria
Practice Characteristics
First-Contact
Longitudinality
Comprehensiveness
Coordination
Family-centeredness
Community orientation
The countries were also scored (0, 1, or 2) with regard to the strength of 6 key characteristics of primary care practice.
Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998.
Source: Starfield, 1998.
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6. Primary Care Scores, 1980s and 1990s
4/19/2017
1980s
1990s
Belgium
France
Germany
United States
Australia
Canada
Japan
Sweden
Denmark
Finland
Netherlands
Spain
United Kingdom
Both in the 1980s and in the 1990s, the countries’ average scores on the 15 characteristics fell into three clear groups: those with poor primary care (including the US), those with intermediate scores, and those with strong primary care.
Starfield 2000
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7. 4/19/2017
System and Practice Characteristics Facilitating Primary Care, Early-Mid 1990s
GER FR
BEL US
SWE
JAP
CAN
FIN
AUS SP
The stronger the health policies for primary care, the stronger the primary care practices. DK
NTH UK
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8. Health Care Expenditures per Capita, 1996
4/19/2017
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
Health expenditures are greater the weaker the primary care.
In the poor primary care group, all but one country has expenditures over 20,000 US dollars per capita.
In the middle primary care group, expenditures were between 15,000 and 20,000 US dollars per capita.
In the good primary care group, all but one country had expenditures of less than 15,000 US dollars per capita.
Starfield 2000
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9. Primary Care Score vs. Health Care Expenditures, 1997
4/19/2017
Primary Care Score vs. Health Care Expenditures, 1997 UK DK
NTH
FIN SP
CAN
AUS
SWE
JAP
The stronger the primary care, the lower the health care expenditures overall, even when the very expensive United States is removed from consideration.
GER US
BEL FR
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10. International Comparisons: Birth Outcomes and Primary Care Score
4/19/2017
Primary Care Score
Low
Med
High 14
11.5 12
9.5 10
Countries with weak primary care infrastructures have poorer health performance. 8
7.3
Average Rankings
5.5 6
4.8
4.6 4
For both low birthweight and postneonatal mortality, the stronger the primary care, the better the ranking of the countries.
Source: Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3): 2
Low: BEL, FR, GER, US
Med: AUS, CAN, JAP, SWE
High: DEN, FIN, NTH, SP, UK
Low BirthWeight
Post Neonatal
Mortality
R= -.74; p<.001
R= -.38 NS
Source: Starfield & Shi, 2002.
Starfield 09/02
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11. 4/19/2017
Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation
All Except Suicide Suicide All Except External
Female Male Female Male Female Male
Lowest
(Belgium,
France,
Germany,
US)
Middle
(Australia,
Canada, Japan,
Sweden)
Highest
(Denmark,
Finland,
Netherlands,
Spain, UK)
Countries with poor primary care have worse rankings for years of potential life lost. Years of potential life lost due to suicide are directly related to the strength of primary care.
Source: OECD. OECD Health Data Paris: OECD Secretariat Health Policy Unit and Centre de Recherch, d'Etude et de Doucementation en Economie de la Santé, 1998.
Source: OECD, 1998.
Starfield 2000
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12. Average Rankings for World Health Organization
Health Indicators for Countries Grouped
by Primary Care Orientation
4/19/2017
DALEs
Child 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
29.1
11.0
15.8
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
For indicators used by the World Health Organization, countries with poor primary care rank worse. This is especially true for child survival (until age 2), for which the poor primary care countries have much poorer rankings and the best primary care countries have the overall best rankings.
Source: World Health Organization. The World Health Report Health Systems: Improving Performance. Geneva: World Health Organization, 2000.
Highest*
(Denmark, Finland,
Netherlands, Spain, UK)
16.0
15.2
31.6
Source: Calculated from WHO, 2000.
Starfield 10/02
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13. 4/19/2017
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
There are 5 characteristics that distinguish better primary care from the poor primary care countries. Three of the 5 are system characteristics, and two are practice characteristics.
Starfield 10/01
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14. Benefits of Primary Care: Within-Country Studies
4/19/2017
Benefits of Primary Care: 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)
Other studies, done in various countries using different methods, also show the benefits of primary care.
Starfield 09/02
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15. Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians per 10,000 Population
4/19/2017
Areas with higher family physician to population ratios have overall lower rates of child hospitalizations for diabetes mellitus and pneumonia, two conditions for which good primary care should reduce hospitalization rates.
Source: Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994; 39(2):
Source: Parchman & Culler, 1994.
Starfield 10/02
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16. State Level Analysis: Primary Care and Life Expectancy
4/19/2017 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 AR WA RI
R=.54
P<.05
States of the US with more primary care physicians per population have higher life expectancy than states with fewer such physicians per population.
Source: Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract 1999; 48(4):
PC physicians/population positively associated with longer life expectancy.
Source: Shi et al., 1999.
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17. Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
4/19/2017
Total
Mortality
Infant
Mortality
.42**
.35*
-.36**
-.29*
Income Inequality
(Robin Hood Index)
-.33*
Both income inequality in a state and the state’s primary care physician to population ratio are related to total mortality, infant mortality, and life expectancy at birth. Other analyses that also consider the effects of sociodemographic and socioeconomic characteristics on low birthweight show an effect of primary care on low birthweight as well. That is, greater primary care physician to population ratios are associated with lower death rates and better life expectancy.
Source: Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract 1999; 48(4):
Primary Care
Physicians
-.37**
.58**
Life
Expectancy
.41**
-.17
Low Birthweight
Source: Shi et al., 1999.
*p<.05; **p<.01.
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18. Postneonatal Mortality
Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
4/19/2017
Life Expectancy
Total
Mortality
Neonatal
Mortality
.39**
.40**
-.35**
-.38**
-.18
Income Inequality
(GINI COEFFICIENT)
-.33*
Primary Care
Physicians
Higher primary care physician to population ratios are associated especially with lower stroke mortality and postneonatal mortality. Income inequality and primary care physician to population ratios are associated with each other, showing that social policies and health policies in individual states go together; the better is one, the better the other.
Source: Shi L, Starfield B, Kennedy BP, Kawachi I. Income inequality, primary care, and health indicators. J Fam Pract 1999; 48(4):
.16
.18
.42**
Stroke Mortality
-.38**
-.33*
Postneonatal Mortality
Life Expectancy
Source: Shi et al., 1999.
*p<.05; **p<.01.
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19. Percent reporting fair or poor health
4/19/2017
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
The effect of primary care on self-reported good health is greater in areas that are more inequitable in income distribution.
Based on information in Shi L, Starfield B. Primary care, income inequality, and self-rated health in the United States: a mixed-level analysis. Int J Health Serv 2000; 30(3):
Based on data in Shi & Starfield, 2000.
Starfield 2000
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20. *compared with population mean
4/19/2017
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 % decrease in mortality
Low primary care resources 6.9% increase in mortality
The effect of primary care in reducing postneonatal mortality is greater in areas that are more inequitable in income distribution.
Based on information in Shi L, Starfield B. Primary care, income inequality, and self-rated health in the United States: a mixed-level analysis. Int J Health Serv 2000; 30(3):
*compared with population mean
Based on data in Shi & Starfield, 2000.
Starfield 2000
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21. Low Birthweight among US Rural, Urban, and Health Center Infants
4/19/2017
Low Birthweight among US Rural, Urban, and Health Center Infants
US urban infants
8.8
Urban health center infants infants
7.5
Geographic area
US rural infants
6.8
Rural health center infants
6.0
African American urban infants
13.6
African American urban health center infants
In both rural and urban areas, and for both all infants as well as just African American infants, those born to users of primary care health centers are less likely to be of low birthweight than infants of mothers who are not users of those centers.
Source: Politzer RM, Yoon J, Shi L, Hughes RG, Regan J, Gaston MH. Inequality in America: the contribution of health centers in reducing and eliminating disparities in access to care. Med Care Res Rev 2001; 58(2):
10.4
Racial composition
African American rural infants
13.0
African American rural health center infants
7.4
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Source: Politzer et al., 2001.
Starfield 09/02
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22. Primary Care and Health: Evidence-Based Summary
4/19/2017
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
Starfield 09/02
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23. Primary Care and Equity: Evidence-Based Summary
4/19/2017
Primary Care and Equity: Evidence-Based Summary
In areas with low social inequity, the additional effect of primary care is small.
In areas of high social inequity, the additional effect of primary care is larger.
Starfield 09/02
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