Starfield
Benefits of Primary Care: Evidence from International Comparisons of 13 Industrialized Countries
Starfield 09/02
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)
Starfield
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 Starfield Source: Starfield, 1998.
Primary Care Orientation of Health Systems: Rating Criteria
• Practice Characteristics
– – – – – – First-Contact Longitudinality Comprehensiveness Coordination Family-centeredness Community orientation
Source: Starfield, 1998.
Starfield
Primary Care Scores, 1980s and 1990s
Belgium France Germany United States Australia Canada Japan Sweden Denmark Finland Netherlands Spain United Kingdom
1980s 0.8 0.5 0.2 1990s 0.4 0.3 0.4 0.4
1.1 1.2 1.2 1.5 1.5 1.5 1.7
1.1 1.2 0.8 0.9 1.7 1.5 1.5 1.4 1.9
Starfield 2000
System and Practice Characteristics Facilitating Primary Care, Early-Mid 1990s
12 11 10 9 8 7 6 5 4 3 2 1 0 0
GER BEL
Practice Characteristics (Rank*)
FR
US
SWE FIN SP DK UK NTH
JAP
CAN
AUS
1
2
3
4
5
6
7
8
9 10 11 12 13
System Characteristics (Rank*)
Starfield 11/00
Health Care Expenditures per Capita, 1996
Belgium ----France ----Germany ----United States ----Australia ----Canada ----Japan ----Sweden ----Denmark ----Finland ----Netherlands ----Spain ----United Kingdom -----
1693 1978 2222 3708 1776 2002 1581 1405
1430 1389 1756 1131 1304
Starfield 2000
Primary Care Score vs. Health Care Expenditures, 1997
2
Primary Care Score
UK DK
1.5
SP
NTH
FIN CAN AUS SWE JAP
1 0.5
GER
BEL FR
US
0 1000
1500
2000
2500
3000
3500
4000
Per Capita Health Care Expenditures
Starfield 10/00
International Comparisons:
Birth Outcomes and Primary Care Score
Primary Care Score
Low 14
Med
11.5
High
Average Rankings
12 10
9.5 7.3
4.8
8 6 4 2 0
5.5
4.6
Countries with weak primary care infrastructures have poorer health performance.
Low BirthWeight Post Neonatal Mortality
R= -.38 NS R= -.74; p<.001
Low: BEL, FR, GER, US Med: AUS, CAN, JAP, SWE High: DEN, FIN, NTH, SP, UK
Source: Starfield & Shi, 2002.
Starfield 09/02
Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation
All Except Suicide
Female Male
Suicide
Female Male
All Except External
Female Male
Lowest 9.5 (Belgium, France, Germany, US) Middle 3.8 (Australia, Canada, Japan, Sweden) Highest 7.6 (Denmark, Finland, Netherlands, Spain, UK)
10.8
7.3
8.3
8.8
10.8
2.8
7.0
7.3
3.8
3.5
7.4
6.8
5.8
8.2
7.0
Source: OECD, 1998.
Starfield 2000
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)
16.3
22.5
36.3
Middle*
(Australia, Canada, Sweden, Japan)
4.8 11.0 16.0
16.5 15.8 15.2
26.0 29.1 31.6
Highest*
(Denmark, Finland, Netherlands, Spain, UK)
Source: Calculated from WHO, 2000.
Starfield 10/02
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
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)
Starfield 09/02
Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians per 10,000 Population
Source: Parchman & Culler, 1994.
Starfield 10/02
State Level Analysis:
Primary Care and Life Expectancy
78 77
Life Expectancy
76 75 74 73 72 71 4.00
. . ID . IA UT . . TN . . TX . . WV DE AR MI . . MS
AL
. ID
. . .. . AZ . . MT . NJ . . NM . FL WI KS . KY . PA . NC . VA .
NE SD ME NH RI IL
.
. ND . OR . NY
. CT . . MN . MA WA . CA
.
HI
.
MD
. GA
. LA
. NV . SC
5.00
. AK
R=.54
P<.05
4.50
5.50
6.00
6.50
7.00
7.50
Primary Care Physicians/10,000 Population
PC physicians/population positively associated with longer life expectancy.
Source: Shi et al., 1999.
Starfield 03/02
Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
Total Mortality
.42**
Income Inequality (Robin Hood Index)
.35*
Infant Mortality
-.36**
-.29*
-.33*
-.37**
Life Expectancy
Primary Care Physicians
.58** -.17
Low Birthweight
Starfield
.41**
Source: Shi et al., 1999.
*p<.05; **p<.01.
Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
Total Mortality Life Expectancy
.39**
-.35**
Income Inequality (GINI COEFFICIENT)
.40** -.18
Neonatal Mortality
-.38**
-.33*
.16
Stroke Mortality
Primary Care Physicians
.18 -.33*
Postneonatal Mortality
-.38**
.42**
Life Expectancy
Source: Shi et al., 1999.
*p<.05; **p<.01.
Starfield
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 Based on data in Shi & Starfield, 2000.
Starfield 2000
Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality, 50 US States, 1990
Areas with low income inequality
High primary care resources Low primary care resources
0.8% decrease in mortality 1.9% increase in mortality
Areas with high income inequality
High primary care resources Low primary care resources
17.1% decrease in mortality 6.9% increase in mortality
*compared with population mean
Based on data in Shi & Starfield, 2000.
Starfield 2000
Low Birthweight among US Rural, Urban, and Health Center Infants
8.8
7.5 6.8 6.0
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
7.4
10.4
13.6
13.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0 14.0
Starfield 09/02
Source: Politzer et al., 2001.
Racial composition Geographic area
US urban infants
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 09/02
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