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Sources:
Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on
populations' health: assessing the evidence. Health Aff 2005;(W5):97-107.
van Doorslaer E, Koolman X, Jones AM. Explaining income-related
inequalities in doctor utilisation in Europe. Health Econ 2004; 13(7):629-647.
Starfield B, Gervas J. Comprehensiveness v special interests: Family
medicine should encourage its clinicians to subspecialize: Negative. In:
Kennealy T, Buetow S, ed. Ideological Debates in Family Medicine. New York,
NY: Nova Publishing, 2007.
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At least in Canada, a task force including specialists recognized that there are
major differences between primary care (generalism) and specialist care. This
is an important step in recognizing the need for fundamental changes in
medical education which is, currently, heavily over-balanced towards training
by specialists. Most critical is the recognition that the training of future
generalists must be in the community and in the context of community
influences rather than in the hospital. Also important is recognizing that
“chronic care” is not the same as the care of chronic illnesses. Rather, it is
person-focused care over time – regardless of the specific diagnosis or
diagnoses – that is important, NOT the diagnosis and management of specific
diseases that people may experience.
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The seeking of care from specialists varies considerably across different health systems. In some
countries, e.g., the United States, it is common for patients to go directly to a secondary care physician
(specialist) without a referral from another health professional (usually a primary care physician). In at least
some parts of Canada, self-referrals are discouraged, as specialists are paid a lower fee in such instances. In
the UK and Spain, seeing a secondary care physician through a referral from primary care is the norm in the
national health system.
The percentage of patients seeing one or more specialists in a year in the United States is very high (at
least 40% of the population, but over half of people who have sought any care) but very variable, and it is much
higher among the elderly, reaching to over 90% in some health care organizations. In Canada and Spain, the
percentage is less and in the UK is about half of that in these two countries – about 15% in the non-elderly. The
extent to which the excess in the US is a result of increased self-referral, poor comprehensiveness of primary
care, historical practice and peoples’ expectations, and/or financial incentives that encourage specialty care is
unknown.
Whatever the explanation, the subject of the role of specialists deserves investigation. In view of the
evidence that much of specialty care may be inappropriate and increasing,1 and that it raises costs of care
unnecessarily, studies of the contributions made by specialists to diagnosis and management are needed, as
are studies of the role of primary care in maintaining comprehensiveness of services in the primary care sector.
Increasing comprehensiveness of care is associated with more effective, efficient, and equitable services in
countries where the subject has been studied.2
1Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing
the evidence. Health Aff 2005; W5:97-107. 2Starfield B, Shi L. Policy relevant determinants of health: an
international perspective. Health Policy 2002; 60(3):201-218.
Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen L, Upshur
REG, Klein-Geltink JE et al. Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative
Sciences, 2006. Sicras-Mainar A, Serrat-Tarres J, Navarro-Artieda R, Llausi-Selles R, Ruano-Ruano I,
Gonzalez-Ares JA. Adjusted Clinical Groups use as a measure of the referrals efficiency from primary care to
specialized in Spain. Eur J Public Health 2007; 17(6):657-663. Starfield B, Chang H, Lemke KW, Weiner JP.
Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. J
Ambul Care Manage 2009;32:216-25.
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Sources:
Forrest CB, Majeed A, Weiner JP, Carroll K, Bindman AB. Comparison of
specialty referral rates in the United Kingdom and the United States:
retrospective cohort analysis. BMJ 2002; 325(7360):370-371.
Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care
provided by office-based specialists in the United States. Ann Fam Med
2009;7:104-11.
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Source: Forrest CB, Reid RJ. Passing the baton: HMOs' influence on
referrals to specialty care. Health Aff 1997; 16(6):157-162.
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Source: Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M.
Ambulatory care provided by office-based specialists in the United States. Ann
Fam Med 2009;7:104-11.
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This chart, from an international population survey in six OECD countries,
shows that people in the US are much less likely to have an ongoing
relationship with a regular doctor than people in any of the other four
countries. Even Germany, which is similar to the US in its greater focus on
specialty and high technology, facilitates good relationships between patients
and medical practitioners. At least twice as many people in the US have no
relationship with a particular doctor as is the case in the other countries; many
fewer people have had a relationship lasting at least five years.
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In European countries, there are vast differences in equity in receipt of
specialty services. In the UK and Netherlands, there are no significant
differences across socioeconomic strata after adjusting for age and health
status. In Norway, there are wide confidence intervals, suggesting possible
variability within the country, leading to small and insignificant differences
overall. In contrast, Denmark, Ireland, Finland, and especially Portugal have
large and very significant differences in access to specialist care across
population subgroups.
Sources:
de Looper M, Lafortune G. Measuring Disparities in Health Status and in
Access and Use of Health Care in OECD Countries. OECD Health Working
Papers No. 43 (http://www.olis.oecd.org/olis/2009doc.nsf/LinkTo/
NT00000DE2/$FILE/JT03260782.PDF, accessed May 26, 2009). Paris,
France: Organization for Economic Cooperation and Development, 2009.
van Doorslaer E, Masseria C. Income-related Inequality in the Use of Medical
Care in 21 OECD Countries. OECD Health Working Paper No. 14 (
http://fiordiliji.sourceoecd.org/vl=22046792/cl=47/nw=1/rpsv/cgi-bin/wppdf?
file=5lgsjhvj7phb.pdf, accessed June 29, 2009). Paris, France: Organization
for Economic Cooperation and Development, 2004.
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Source: Spitzer M. Personal communication. ACG Users Conference,
September 2000.
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Total morbidity burden has a great impact on use of secondary care physicians
relative to primary care physicians, at least in the United States. This slide shows
how the presence of high morbidity burden influences the relative use of primary and
secondary care among the elderly, at least in the United States.
When the number of visits is analyzed according to the extent of the patient’s
comorbidity (diagnoses additional to any specified main diagnosis), it is the visits for
comorbid diagnoses that are associated with a high number of visits made by the
non-elderly to primary care physicians and specialists. When their total morbidity
burden is very high, patients make over 3 times as many visits to primary care
physicians as compared with patients with low morbidity burdens, but they make over
6 times as many visits to specialists as compared with those with low morbidity
burdens. The ratios between the number of visits to primary care physicians and
visits to secondary care physicians falls from about 3 when total morbidity is low to
about 2 when total morbidity burden is high, to about 1.3 when total morbidity burden
is very high. The extent to which the high use of disease- and procedure-oriented
physicians in the presence of high morbidity burden is appropriate and advantageous
to health is unknown. At least a case could be made that primary care is even more
important in the presence of high morbidity burdens because of the increased need
for coordination of care.
Based on data in Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner
JP. Comorbidity: implications for the importance of primary care in 'case'
management. Ann Fam Med 2003; 1:8-14.
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For the elderly in the United States, the additional visits to specialists in
a year resulting from comorbid diagnoses are even more striking than in
the case for the non-elderly: For the elderly, visits to specialists actually
exceed the number of visits to primary care physicians in the case of
individuals with intermediate total morbidity burdens (ratio of primary
care visits to specialty care visits of about 0.9) and even more so when
total morbidity burden is very high (ratio of 0.7). Only in the case of low
total morbidity burden does the number of visits to primary care
physicians exceed the number of visits to specialists (with a ratio of
about 1.2) That is, a very large number of visits to specialists (relative
to primary care physicians), just in situations wherein the coordinating
role of primary care would be expected to be most essential.
Source: Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G.
Comorbidity and the use of primary care and specialist care in the
elderly. Ann Fam Med 2005; 3(3):215-222.
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These data from the United States show that new problems constitute a nearmajority of reasons for primary care visits. The proportion for routine follow-up
of known problems differs across the three primary care physician types, being
greater in general internist visits. Except for surgical specialists, well over half
of specialist visits are for routine follow-up, suggesting a possible mismatch
between the need for specialist expertise and actual use of their services.
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Source: Starfield B, Shi L, Grover A, Macinko J. The effects of specialist
supply on populations' health: assessing the evidence. Health Aff
2005;W5:97-107.
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Sources:
Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic
variation in expenditures for physicians' services in the United States. N
Engl J Med 1993; 328(9):621-627.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL.
The implications of regional variations in Medicare spending. Part 1: the
content, quality, and accessibility of care. Ann Intern Med 2003; 138(4):
273-287.
Baicker K, Chandra A. Medicare spending, the physician workforce, and
beneficiaries' quality of care. Health Aff 2004; W4(April 7):184-197
(http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf ).
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Sources:
Starfield B, Shi L. Policy relevant determinants of health: an international
perspective. Health Policy 2002; 60(3):201-218.
Franks P, Fiscella K. Primary care physicians and specialists as personal
physicians. Health care expenditures and mortality experience. J Fam Pract
1998; 47(2):105-109.
Baicker K, Chandra A. The productivity of physician specialization: evidence
from the Medicare program. Am Econ Rev 2004; 94(2):357-361.
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Sources:
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The
implications of regional variations in Medicare spending. Part 1: the content,
quality, and accessibility of care. Ann Intern Med 2003; 138(4):273-287.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The
implications of regional variations in Medicare spending. Part 2: health
outcomes and satisfaction with care. Ann Intern Med 2003; 138(4):288-298.
Baicker K, Chandra A. Medicare spending, the physician workforce, and
beneficiaries' quality of care. Health Aff 2004; W4(April 7):184-197 (
http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf).
Wennberg JE, Fisher ES, Baker L, Sharp SM, Bronner KK. Evaluating the
efficiency of California providers in caring for patients with chronic illnesses.
Health Aff 2005; W5:526-543 (
http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.526v1).
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Source: Weingarten SR, Lloyd L, Chiou CF, Braunstein GD. Do subspecialists
working outside of their specialty provide less efficient and lower-quality care
to hospitalized patients than do primary care physicians? Arch Intern Med
2002; 162(5):527-532.
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Source: Chin MH, Zhang JX, Merrell K. Specialty differences in the care of
older patients with diabetes. Med Care 2000; 38(2):131-140.
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Sources:
Hartz A, James PA. A systematic review of studies comparing myocardial
infarction mortality for generalists and specialists: lessons for research and
health policy. J Am Board Fam Med 2006; 19(3):291-302.
Chin MH, Zhang JX, Merrell K. Specialty differences in the care of older
patients with diabetes. Med Care 2000; 38(2):131-140.
Donohoe MT. Comparing generalist and specialty care: discrepancies,
deficiencies, and excesses. Arch Intern Med 1998; 158(15):1596-1608.
Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician
practice styles and patient outcomes: differences between family practice and
general internal medicine. Med Care 1998; 36(6):879-891.
Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes
of care for generalists and specialists. J Gen Intern Med 1999; 14(8):499-511.
Smetana GW, Landon BE, Bindman AB et al. A comparison of outcomes
resulting from generalist vs specialist care for a single discrete medical
condition: a systematic review and methodologic critique. Arch Intern Med
2007; 167(1):10-20.
Other studies reported in: Starfield B, Shi L, Macinko J. Contribution of primary
care to health systems and health. Milbank Q 2005; 83(3):457-502.
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Source: Starfield B, Shi L, Grover A, Macinko J. The effects of specialist
supply on populations' health: assessing the evidence. Health Aff
2005;W5:97-107.
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The poorer health outcome when specialist supply is very high is robust, and
is found for different causes of mortality in different types of geographic areas.
Source: Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The
relationship between primary care, income inequality, and mortality in US
States, 1980-1995. J Am Board Fam Pract 2003; 16(5):412-422.
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Source: Goodman DC, Fisher ES, Little GA, Stukel TA, Chang CH,
Schoendorf KS. The relation between the availability of neonatal
intensive care and neonatal mortality. N Engl J Med 2002; 346(20):
1538-1544.
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Source: Goodman DC, Fisher ES, Little GA, Stukel TA, Chang CH,
Schoendorf KS. The relation between the availability of neonatal
intensive care and neonatal mortality. N Engl J Med 2002; 346(20):
1538-1544.
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Source: OECD. Health at a Glance, 2003. Paris: OECD.
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Sources:
Ferrante JM, Gonzalez EC, Pal N, Roetzheim RG. Effects of physician supply
on early detection of breast cancer. J Am Board Fam Pract 2000; 13(6):
408-414.
Roetzheim RG, Pal N, Van Durme DJ, Wathington D, Ferrante JM, Gonzalez
EC et al. Increasing supplies of dermatologists and family physicians are
associated with earlier stage of melanoma detection. J Am Acad Dermatol
2000; 43(2 Pt 1):211-218.
Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ, Ayanian JZ
et al. The effects of physician supply on the early detection of colorectal
cancer. J Fam Pract 1999; 48(11):850-858.
Campbell RJ, Ramirez AM, Perez K, Roetzheim RG. Cervical cancer rates
and the supply of primary care physicians in Florida. Fam Med 2003; 35(1):
60-64.
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Sources:
Heneghan C, Alonso-Coello P, Garcia-Alamino JM, Perera R, Meats E,
Glasziou P. Self-monitoring of oral anticoagulation: a systematic review and
meta-analysis. Lancet 2006;367:404-11.
Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary
care physicians: a meta-analysis. Ann Fam Med 2009;7:56-62.
Shaw IS, Valori RM, Charlett A, McNulty CA. Limited impact on endoscopy
demand from a primary care based 'test and treat' dyspepsia management
strategy: the results of a randomised controlled trial. Br J Gen Pract
2006;56:369-74.
Gervas J. Personal communication. 2008.
Shaffrey TA. Personal communication. 2009.
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Source: Leese B. Comprehensiveness v special interests: Family medicine
should encourage its clinicians to subspecialize. In Kennealy T, Buetow S.
Ideological Debates in Family Medicine. New York, NY: Nova Publishing,
2007.
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Source: Leese B. Comprehensiveness v special interests: Family medicine
should encourage its clinicians to subspecialize. In Kennealy T, Buetow S.
Ideological Debates in Family Medicine. New York, NY: Nova Publishing,
2007.
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Source: Starfield B, Gervas J. Comprehensiveness v special interests. Family
medicine should encourage its clinicians to specialize: Negative. In Kennealy
T, Buetow S. Ideological Debates in Family Medicine. New York, NY: Nova
Publishing, 2007.
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