Transcript Dias nummer 1 - Nordic Congress > Welcome

General Practice as an
Integral Part of the Health
System
Barbara Starfield, MD, MPH
16th Nordic Conference on General Practice
Copenhagen, Denmark
May 13-16, 2009
Life Expectancy Compared with GDP
per Capita for Selected Countries
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
Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK:
Economist Intelligence Unit, 1999.
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
Starfield 11/06
IC 3493 n
Country* Clusters: Health Professional
Supply and Child Survival
25
15
Density (workers per 1000)
10
5.0
2.5
1
3
*186 countries
5
9
50
100
Child mortality (under 5) per 1000 live births
Source: Chen et al, Lancet 2004; 364:1984-90.
250
Starfield 07/07
HS 3754 n
Primary health care is primary
care applied on a population
level. As a population strategy,
it requires the commitment of
governments to develop a
population-oriented set of
primary care services in the
context of other levels and
types of services.
Starfield 07/07
PC 3755 n
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 07/07
PC 3756 n
Why Is Primary Care
Important?
Better health outcomes
Lower costs
Greater equity in health
Starfield 07/07
PC 3757 n
Evidence for the benefits of primary care-oriented
health systems is robust across a wide variety of
types of studies:
• International comparisons
• Population studies within countries
– across areas with different primary care
physician/population ratios
– studies of people going to different types of
practitioners
• Clinical studies
– of people going to facilities/practitioners differing
in adherence to primary care practices
Source: Starfield et al, Milbank Q 2005; 83:457-502.
Starfield 03/08
PC 3971 n
Primary Care Scores, 1980s and 1990s
1980s
1990s
Belgium
France*
Germany
United States
0.8
0.5
0.2
0.4
0.3
0.4
0.4
Australia
Canada
Japan*
Sweden
1.1
1.2
1.2
1.1
1.2
0.8
0.9
Denmark
Finland
Netherlands
Spain*
United Kingdom
1.5
1.5
1.5
1.7
1.7
1.5
1.5
1.4
1.9
*Scores available only for the 1990s
Starfield 07/07
ICTC 3758 n
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. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998.
Starfield
Starfield11/02
11/02
PC
02-405
2366sc
n
System Features Important to Primary Health Care
Resource
Allocation Progressive
Cost
Compre(Score)
Financing* Sharing hensiveness
Belgium
France
Germany
US
0
0
0
0
0
0
1
0**
0
0
2
0
0
0
0
0
Australia
Canada
Japan
Sweden
1
1
1
2
2
2
2
2
2
2
1
1
2
2
1
1
Denmark
Finland
Netherlands
Spain
UK
2
2
2
2
2
2
2
0
2
2
2
1
2
2
2
2
2
2
1
2
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998. van Doorslaer et al. Equity in the Finance and
Delivery of Health Care: An International Perspective. Oxford U. Press, 1993.
*0=all regressive
1=mixed
2=all progressive
**except Medicaid
Starfield 11/06
EQ 3500 n
Key system factors in achieving primary
health care in both developing and
industrialized countries are:
• Universal financial coverage, under
governmental control or regulation
• Efforts to distribute resources equitably
(according to degree of need)
• No or low co-payments
• Comprehensiveness of services
Sources: Starfield & Shi, Health Policy 2002; 60:201-18. Gilson
et al, Challenging Inequity through Health Systems
(http://www.who.int/social_determinants/resources/csdh_media
/hskn_final_2007_en.pdf; accessed March 17, 2009).
Starfield 07/07
GH 3794 n
More Comprehensive Health Centres Have Better
Vaccination Coveragea,b
Source: World Health Organization. The World Health Report 2008:
Primary Health Care – Now More than Ever. Geneva, Switzerland, 2008.
Starfield 05/09
COMP 4188
Primary Care Orientation of
Health Systems: Rating Criteria
• Practice Characteristics
– First-contact
–
–
–
–
–
Person-focus over time
Comprehensiveness
Coordination
Family-centeredness
Community orientation
Source: Starfield. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998.
Starfield 04/09
PC 4180 n
PC 4181
• First contact avoids unnecessary specialist
visits.
• Person-focus over time avoids diseasefocused care (makes care more effective).
• Comprehensiveness avoids referrals for
common needs (makes care more
efficient).
• Coordination avoids duplication and
conflicting interventions (makes care less
dangerous).
Starfield 04/09
PC 4181
Practice Characteristics
(Rank*)
System (PHC) and Practice (PC) Characteristics
Facilitating Primary Care, Early-Mid 1990s
12
11
10
9
8
7
6
5
4
3
2
1
0
GER
FR
BEL
US
SWE
JAP
CAN
FIN
AUS
SP
DK
NTH
UK
0
1
2
3
4
5
6
7
8
9 10 11 12 13
System Characteristics (Rank*)
*Best level of health indicator is ranked 1; worst is ranked 13;
thus, lower average ranks indicate better performance.
Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.
Starfield 03/05
ICTC 3099 n
Primary Care Score vs. Health
Care Expenditures, 1997
Primary Care Score
2
UK
DK
NTH
1.5
FIN
SP
CAN
AUS
1
SWE
JAP
0.5
GER
BEL
0
1000
1500
US
FR
2000
2500
3000
3500
4000
Per Capita Health Care Expenditures
Starfield 11/06
ICTC 3495 n
Primary Care Strength and Premature
Mortality in 18 OECD Countries
10000
PYLL
Low PC Countries*
5000
High PC Countries*
0
1970
1980
Year
1990
2000
*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.
Starfield 11/06
Source: Macinko et al, Health Serv Res 2003; 38:831-65.
IC 3496 n
Primary Care Oriented
Countries Have
• Fewer low birth weight infants
• Lower infant mortality, especially
postneonatal
• Fewer years of life lost due to suicide
• Fewer years of life lost due to “all except
external” causes
• Higher life expectancy at all ages except
at age 80
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.
Starfield 07/07
IC 3762 n
The global imperative is to organize health
systems around strong, patient-centered, i.e.,
Primary Care.
A disease-by-disease approach will not
address the most serious shortfall in
achieving the health-related Millennium
Development Goals. It will also worsen global
inequities. Those exposed to a variety of
interacting influences are vulnerable to many
diseases. Eliminating diseases one by one
will not materially reduce the chances of
others.
Sources: IBRD/World Bank, April 8, 2008. King
& Bertino, PLoS Negl Trop Dis 2008;2:e209.
Starfield 03/08
GH 3992
Is Primary Care as
important within
countries as it is among
countries?
Starfield 07/07
WC 3765 n
State Level Analysis:
Primary Care and Life Expectancy
78
HI
77
MN
Life expectancy at birth
76
IA
ND
UT
NE
ID
75
SD
74
OK
MI
IN
MO
TX
OH
DE
73
AL
NV
GA
TN
KY
VA
KS
SC
WA
MA
CT
VT
CA
MT
NY
IL
MD
NC
WV
AK
MS
72
NH
OR
NJ
PA FL
WY
WI
RI
ME
AZ
NM
AR
CO
LA
71
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
Primary care physicians per 10,000 population
Source: Shi, Int J Health Serv 1994;24:431-58.
Starfield 04/09
WCUS 4178 n
Primary Care and Infant Mortality
Rates, Indonesia, 1996-2000
1996-1997
Primary care
spending
per capita*
1999-2000
10.3
9.6
8.5
8.2
4.1
4.4
4.6
5.3
Hospital
spending
per capita*
Infant
mortality
1997- 19981998 1999
20% improvement
(all provinces)
(1990-96)
*constant Indonesian rupiah, in billions
Source: Simms & Rowson, Lancet 2003; 361:1382-5.
14% worsening
(22 of 26 provinces)
Starfield 07/07
WC 3796 n
Primary Care Score and Self-Rated
Health, Petrópolis, Brazil, 2004*
(n=455)
Primary care score (0-5)
Odds Ratio
1.452
95% CI**
1.073, 1.966
Age (years)
Chronic disease (yes/no)
Recent illness (yes/no)
Household wealth (scale 1-8)
0.969
0.578
0.176
1.219
0.957, 0.981
0.360, 0.927
0.098, 0.316
1.007, 1.476
Completed primary school
Clinic type
(0=traditional; 1=PSF)
0.733
0.374, 1.437
0.998
0.594, 1.679
*1= excellent/ good health; 0=bad/fair/poor health
** standard errors adjusted for clustering by clinic
Source: Macinko, Almeida, de Sá, Health Policy Plan 2007; 22:167-77.
Starfield 07/07
WC 3768 n
Impact of PSF Coverage on Infant Mortality in
Brazilian States, 1990-2002: Marginal Effects*
Illiteracy
(women)
PSF coverage
Clean water
Fertility rate
Hospital beds
-5
0
5
10
15
Marginal effect (% change in IMR with 10% increase in variable)
*Based on 2-way fixed effects model of Brazilian states, 1990-2002, n=351 R^2=0.90. Non-significant
(p>0.05) control variables, including physician and nurse supply and sewage not shown.
Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.
Starfield 10/06
WC 3457 n
Many other studies done WITHIN countries,
both industrialized and developing, show that
areas with better primary care have better
health outcomes, including total mortality
rates, heart disease mortality rates, and
infant mortality, and earlier detection of
cancers such as colorectal cancer, breast
cancer, uterine/cervical cancer, and
melanoma. The opposite is the case for
higher specialist supply, which is associated
with worse outcomes.
Sources: Starfield et al, Milbank Q 2005;83:457-502.
Macinko et al, J Ambul Care Manage 2009;32:150-71.
Starfield 09/04
04-167
WC
2957
What We Already Know
A primary care oriented system is
important for
• Improving health (improving
effectiveness)
• Keeping costs manageable (improving
efficiency)
Starfield 09/05
PC 3316
Does primary care
reduce inequity in
health?
Starfield 07/07
EQ 3769 n
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.
Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.
Starfield 07/07
WCUS 3770 n
Percentage Reduction in Under-5
Mortality: Thailand, 1990-2000
Poorest quintile (1)
44
Policy changes:
(2)
41
(3)
22
1989 At least one primary care health
center for each rural village
(4)
23
Richest quintile (5)
13
Rate ratio (Q1/Q5)
55
Absolute difference
(Q1-Q5)
61
Source: Vapattanawong et al, Lancet 2007; 369:850-5.
1993 Government medical welfare
scheme: all children less than 12,
elderly, disabled
2001 Entire adult population insured
Activities of Rural Doctors’ Society
Starfield 07/07
WC 3797 n
Why Does Primary Care Enhance
Equity in Health?
• Greater comprehensiveness of services
(especially important in the presence of multimorbidity)
• Person-focused care over time (better knowledge
of patient and better recognition of problems)
• Greater accessibility of services
• Better coordination, thus facilitating care for
people of limited flexibility
• Better person-focused prevention
Source: Starfield et al, Milbank Q 2005;83:457-502.
Starfield 05/09
PC 4184
Why Does Primary Care Enhance
Effectiveness of Health Services?
• Greater accessibility
• Better person-focused prevention
• Better person-focused quality of clinical
care
• Earlier management of problems (avoiding
hospitalizations)
• The accumulated benefits of the four
features of primary care
Source: Starfield et al, Milbank Q 2005;83:457-502.
Starfield 05/09
PC 4185
Primary health care oriented countries
• 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
Sources: Starfield and Shi, Health Policy 2002; 60:201-18.
van Doorslaer et al, Health Econ 2004; 13:629-47.
Schoen et al, Health Aff 2005; W5: 509-25.
Starfield 11/05
IC 3326
Primary Care and Health:
Evidence-Based Summary
• 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
Starfield09/02
09/02
PC
02-437
2218sc
n
Conclusion
Although sociodemographic factors
undoubtedly influence health, a primary
care oriented health system is a highly
relevant policy strategy because its
effect is clear and relatively rapid,
particularly concerning prevention of
the progression of illness and effects of
injury, especially at younger ages.
Starfield 11/05
HS 3329
Strategy for Change in Health
Systems
•
•
•
•
•
•
•
•
•
Achieving primary care
Avoiding an excess supply of specialists
Achieving equity in health
Addressing co- and multi-morbidity
Responding to patients’ problems
Coordinating care
Avoiding adverse effects
Adapting payment mechanisms
Developing information systems that serve
care functions as well as clinical information
Starfield 11/06
HS 3494 n
Health Workforce
Starfield 10/07
WF 3901
In 35 US 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.
Above a certain level of specialist supply, the
more specialists per population, the worse
the outcomes.
Controlled only for income inequality
Source: Shi et al, J Am Board Fam Pract 2003; 16:412-22.
Starfield 11/06
SP 3499 n
Percentage of People Seeing at
Least One Specialist in a Year
US
Canada
(Ontario)
40% of total population; 54% of
patients (users)
31% of population (68% at ages
65 and over)
UK
about 15% of patients (at ages
under 65)
Spain
30% of population; 40% of
patients (users)
Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen et al.
Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative Sciences,
2006. Sicras-Mainar et al, Eur J Public Health 2007; 17:657-63. Starfield et al, submitted 2008.
Starfield 01/07
SP 3529 n
Resource Use, Controlling for Morbidity
Burden*
• More DIFFERENT specialists seen: higher total costs,
medical costs, diagnostic tests and interventions, and
types of medication
• More DIFFERENT generalists seen: higher total costs,
medical costs, diagnostic tests and interventions
• More generalists seen (LESS CONTINUITY): more
DIFFERENT specialists seen among patients with high
morbidity burdens. The effect is independent of the
number of generalist visits. That is, the benefits of
primary care are greatest for people with the greatest
burden of illness.
*Using the Johns Hopkins Adjusted Clinical Groups (ACGs)
Source: Starfield et al, Ambulatory specialist use by patients in US health plans:
correlates and consequences. J Ambul Care Manage 2009 forthcoming.
Starfield 09/07
CMOS 3854
Percent of Patients Reporting Any
Error by Number of Doctors Seen
in Past Two Years
Country
One doctor 4 or more doctors
Australia
12
37
Canada
15
40
Germany
14
31
New Zealand
14
35
UK
12
28
US
22
49
Source: Schoen et al, Health Affairs 2005; W5: 509-525.
Starfield 09/07
IC 3870 n
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.
Sources: Fisher et al, Ann Intern Med 2003; Part 1: 138:273-87; Part 2: 138:288-98. Baicker &
Chandra, Health Aff 2004; W4:184-97. Wennberg et al, Health Aff 2005; W5:526-43.
Starfield 12/05
SP 3343
What is the right number of
specialists?
What do specialists do?
What do specialists contribute
to population health?
Starfield 01/06
SP 3354
Enhancements to Primary Care
• Health information systems: primary care/system-wide
• Analysis of variations in care
– with variations in use of secondary care
– with variations in type of payment
– with focus on patients versus diseases (P4P)
• Subspecialization in primary care
• Patient-centered primary care (poorly conceptualized)
• “Chronic care model”: self-management support;
delivery system design; decision support; clinical;
information systems
ALL REQUIRE EVALUATION.
Starfield 02/08
PC 3966
Any evaluation of enhancements to clinical
primary care must consider the extent to
which they better achieve the evidencebased primary care functions:
• First contact for new needs/problems
• Person (not disease) focused care
(enhanced recognition of people’s health
problems)
• Breadth of services
• Coordination (enhanced problems/needs
recognition over time)
Starfield 06/08
EVAL 4044
Good Primary Care Requires
• Health system POLICIES conducive
to primary care practice
• Health services delivery that achieves
the important FUNCTIONS of primary
care
Starfield 06/08
PC 4042
The impact of a health services intervention
should not be evaluated on the basis of a
structural element of health systems alone. The
value of health system structures lies only in
the behaviors that they engender. In order to
understand why and how things have an
impact, it is necessary to evaluate the impact of
structures on processes of care. That is why
evaluations of structures such as type or
number of practitioners, electronic health
records, and the Chronic Care Model (CCM)
have inconsistent results.
Starfield 10/08
EVAL 4072
The Health Services System
Personnel
Facilities and equipment
Range of services
Organization
Management and amenities
Continuity/information systems
Knowledge base
Accessibility
Financing
Population eligible
Governance
CAPACITY
Provision
of care
PERFORMANCE
Problem recognition
Diagnosis
Management
Reassessment
Community
resources
Cultural and
behavioral
characteristics
People/practitioner interface
Receipt
of care
HEALTH STATUS
(outcome)
Biologic endowment
and prior health
Source: Starfield. Primary Care:
Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998.
Utilization
Acceptance and satisfaction
Understanding
Participation
Longevity
Comfort
Perceived well-being
Disease
Achievement
Risks
Resilience
Social, political,
economic, and
physical
environments
Starfield 02/09
HS 4133 n
PCAT
(Primary Care Assessment Tool)
• First-contact (access and use)
• Person-focused care over time
• Comprehensiveness (services available
and provided)
• Coordination
• Family centered
• Community oriented
• Culturally competent
Starfield 05/03
03-095
PCM
2479
Primary Care Scores by Data Source, PSF Clinics
Access
5
4
Total Score
Longitudinal
3
2
Resources
Providers
Available
1
First
Contact
Gatekeeping
0
Community
Comprehensive
Family focus
PSF (users)
Coordination
PSF (providers)
Source: Almeida & Macinko. [Validation of a Rapid Appraisal Methodology for
Monitoring and Evaluating the Organization and Performance of Primary Health Care
Systems at the Local Level]. Brasília: Pan American Health Organization, 2006.
PSF (managers)
Starfield 05/06
WC 3421 n
There is no such thing as a “primary care
service”. There are only primary care
functions and “specialty care” functions. We
know what the primary care functions are;
they are evidence-based. Payment should
be based on their achievement over a period
of time. Any payment system that rewards
specific services will distort the main
purpose of medical care: to deal with health
problems effectively, efficiently, and
equitably.
Starfield 06/08
PC 4046
Primary Care
First Contact
• Accessibility
• Use by people for each new problem
Longitudinal
• Relationship between a facility and its
population
• Use by people over time regardless of the type
of problem; person-focused character of
provider/patient relationship
Comprehensive
• Broad range of services
• Recognition of situations where services are
needed
Coordination
• Mechanism for achieving continuity
• Recognition of problems that require follow-up
Starfield 02/08
EVAL 3968 n
Structural and Process Elements of the
Essential Features of Primary Care
Capacity
Accessibility
Essential Features
Performance
First-contact
Utilization
Eligible population
Longitudinality
Range of services
Comprehensiveness
Person-focused
relationship
Problem recognition
Continuity
Coordination
Starfield
Starfield04/97
1997
EVAL
97-194
1108 n
Structural and Process Elements of the
Essential Features of Primary Care
Capacity
Accessibility
Essential Features
Performance
First-contact
Utilization
Eligible population
Longitudinality
Range of services
Comprehensiveness
Person-focused
relationship
Problem recognition
Continuity
Coordination
Starfield 10/08
EVAL 4071 n
Welcome to the 16th Nordic
Congress of General Practice