Comprehensiveness of
Care: Concept and
Importance
Barbara Starfield, MD
Presented at:
RNZCGP Annual Quality Symposium
Wellington, NZ
February 14, 2009
“Basic Coverage” versus
Comprehensive Primary Care
“Basic coverage”: e.g., all ages, care by
doctors, hospitals, prescription drugs,
lab/diagnostic tests. (HEALTH SYSTEM
responsibility)
Comprehensive primary care: a range of
services broad enough to care for all health
needs except those too uncommon to
maintain competence. (Who provides and
Where)
Starfield 01/09
COMP 4117
What Is Comprehensiveness
in Primary Care?
Dealing with all health-related problems
or interventions except those too
uncommon to maintain competence
(“common” = encountered in at least
one per thousand patients in a year)
Starfield 01/07
COMP 3536
Comprehensiveness is the
feature of primary care
practice that is most salient
in distinguishing primary
care-oriented countries from
other countries.
Starfield 01/07
COMP 3571
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
Criteria for Comprehensiveness
In US studies: universal provision of extensive and
uniform benefits for children, the elderly, women, and
other adults; routine OB care; mental health needs
addressed; minor surgery; generic preventive care
In European studies: treatment and follow-up of diseases
(e.g., hypothyroidism, acute CVA, ulcerative colitis, workrelated stress, n=17); technical procedures (e.g., wart
removal, IUD insertion; removal of corneal rusty spot;
joint injections); taking cervical smears; group health
education; family planning and contraception
Sources: Starfield &Shi, Health Policy 2002; 60:201-18; Boerma et al, Br J
Gen Pract 1997; 47:481-6; Boerma et al, Soc Sci Med 1998; 47:445-53.
Starfield 10/07
COMP 3891
Specialty services are more
costly than primary care
services, both from the
systems viewpoint and from
the viewpoint of individuals
followed over time. This is
especially the case for
medical subspecialists.
Sources: Starfield & Shi, Health Policy 2002; 60:201-18.
Franks & Fiscella, J Fam Pract 1998; 47:105-9. Baicker
& Chandra, Am Econ Rev 2004; 94:357-61.
Starfield 05/06
SP 3417
Although specialists usually do better at
adhering to disease-oriented guidelines,
generic outcomes of care (especially but not
only patient-reported outcomes) are no
better and are often worse than when care is
provided by primary care physicians.
Studies finding specialist care to be superior
are more likely to be methodologically
unsound, particularly regarding failure to
adjust for case mix.
Sources: Hartz & James, J Am Board Fam Med 2006; 19:291-302. Chin et al, Med Care 2000;
38:131-40. Donohoe, Arch Intern Med 1998; 158:1596-1608. Bertakis et al, Med Care 1998;
36:879-91. Harrold et al, J Gen Intern Med 1999; 14:499-511. Smetana et al, Arch Intern Med
2007; 167:10-20. Other studies reported in: Starfield et al, Milbank Q 2005; 83:457-502.
Starfield 04/07
SP 3700
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
SP 2964
• 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)
Sources: Welch et al, N Engl J Med 1993; 328:621-7. Fisher et al, Ann Intern
Med 2003; 138:273-87. Baicker & Chandra. Health Aff 2004; W4(April 7):184197 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf).
Starfield 09/04
04-145
SP
2964
Royal College of Physicians and Surgeons
Task Force to Review Fundamental Issues in
Specialty Education
GENERALISM
SPECIALISM
Knowledge
Breadth
Depth
Multidisciplinary
Single discipline
Undifferentiated
Differentiated
Prevention, investigation/ management/
rehabilitation and chronic care
Investigation/management
Disease is considered in the context of
multiple systems and the whole.
Disease is considered in the context of a
single system.
Community- and hospital-based
Hospital-based
Skills
Predominantly non-invasive
Predominantly invasive
Attitudes
Holistic
Reductionist
Starfield 01/09
SP 4085
Comprehensiveness is a critical feature of
primary care because it is responsible for
avoiding referrals for common needs in the
population and hence for saving
unnecessary expenditures.
Comprehensiveness is measured by the
availability in primary care of a wide range of
services to meet common needs, and by
demonstrating that care is, indeed, provided
for a broad range of problems and needs.
Starfield 09/08
COMP 4065
Assessment of
Comprehensiveness
• Assess the range of services available in primary
care: diagnosis and management of all common
problems in the population, mental health problems,
minor surgery, indicated screening for disease,
common minor procedures, common follow-up
needs. (Normative measure)
• Determine the cumulative percentage contributed by
visits for the most common problems. The higher the
percentage, the greater the breadth of services
provided. (Empirical measure)
Sources: Rivo et al, JAMA 1994; 271:1499-1504. Boerma et al, Br J Gen Pract 1997; 47:481-6.
Starfield 01/07
COMP 3538
Comprehensiveness in Primary Care
Wart removal
IUD insertion
IUD removal
Pap smear
Suturing lacerations
Tympanocentesis
Removal of cysts
Vision screening
Joint aspiration/injection
Foreign body removal (ear, nose)
Setting of simple fractures
Sprained ankle splint
Age-appropriate surveillance
Family planning
Immunizations
Smoking counseling
Remove ingrowing toenail
Hearing screening
Behavior/MH counseling
Home visits as needed
Electrocardiography
Nutrition counseling
Examination for dental status
OTHERS?
Starfield 03/08
COMP 4008
In New Zealand, Australia, and the US,
an average of 1.4 problems (excluding
visits for prevention) were managed in
each visit. However, primary care
physicians in the US managed a narrower
range: 46 problems accounted for 75% of
problems managed in primary care, as
compared with 52 in Australia and 57 in
New Zealand.
Source: Bindman et al, BMJ 2007; 334:1261-6.
Starfield 01/07
COMP 3537
Assessment of
Comprehensiveness May Differ
from Place to Place
Comprehensiveness means that
primary care meets all health-related
needs of the population except those
that are too uncommon to maintain
competence. This will differ from
place to place.
Starfield 04/04
04-047 2817
COMP
Primary Care Oriented Health Services
CAPACITY
Provision
of care
PERFORMANCE
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.
Personnel
Facilities and equipment
Range of services
Organization
Management and amenities
Continuity/information systems
Knowledge base
Accessibility
Financing
Population eligible
Governance
Problem recognition
Diagnosis
Management
Reassessment
Community
resources
Cultural and
behavioral
characteristics
Person-focused relationship
Utilization
Acceptance and satisfaction
Understanding
Participation
Longevity
Comfort
Perceived well-being
Disease
Achievement
Risks
Resilience
Social, political,
economic, and
physical
environments
Starfield 04/08
HS 4139 n
The Health Services System: Comprehensiveness
Range of services
CAPACITY
Provision
of
care
Problem recognition
PERFORMANCE
Receipt of
care
HEALTH STATUS
(outcome)
Source: Starfield. Primary Care:
Balancing Health Needs, Services, and
Technology. Oxford U. Press, 1998.
Starfield
Starfield1999
1999
HS
99-014
1441
PCAT: Comprehensiveness
Subdomains
Services available
Services provided (received)
Starfield 01/02
02-022
PCM
2047
Primary Care Domains and
Subdomains: Comprehensiveness
Comprehensiveness: services available
• Availability of 11 specific services, e.g.,
family planning.
Comprehensiveness: services provided
• Services received from the primary care
source, e.g., discussions of ways to stay
healthy.
Starfield
Starfield05/96
1996
PCM
96-24
1017
PCAT: Comprehensiveness
(Services Available*)
Following is a list of services that you or your
family might need at some time. For each one,
please indicate whether it is available at your
PCP’s office.
1.
2.
3.
4.
Family planning or birth control methods
Counseling for mental health problems
Sewing up a cut that needs stitches
Vision screening
*Examples
Starfield 01/02
02-027
PCM
2052
PCAT: Comprehensiveness
(Services Provided*)
In visits to your PCP, are any of the following
things discussed with you?
1. Advice about healthy foods and unhealthy
foods
2. Ways to handle family conflicts that may
arise from time to time
3. Advice about appropriate exercise for you
4. Checking on and discussing the medications
you are taking
*Examples
Starfield 01/02
02-028
PCM
2053
Specialist societies are often strong enough to prevent
primary care from providing services that are provided in
primary care elsewhere and despite evidence that they can
be provided safely in primary care.
•
•
•
•
•
•
monitoring anticoagulant therapy in atrial fibrillation
routine colonoscopy
early voluntary abortion
management of insulin-dependent diabetes (Belgium)
reduction of dislocated toe
injection of vitamin B12 in iatrogenic pernicious anemia
secondary to gastric bypass
• H. pylori screening
Sources: Heneghan et al, Lancet 2006;367:404-11. Wilkins et al, Ann Fam Med 2009;7:56-62.
Shaw et al, Br J Gen Pract 2006;56:369-74. Gervas J, Personal communication 2008.
Shaffrey TA, Personal communication 2009.
Starfield 01/09
SP 4118
We know that
1. Inappropriate referrals to specialists lead to
greater frequency of tests and more false positive
results than appropriate referrals to specialists.
2. Inappropriate referrals to specialists lead to poorer
outcomes than appropriate referrals.
3. The socially advantaged have higher rates of visits
to specialists than the socially disadvantaged.
4. The more the training of MDs, the more the
referrals.
A MAJOR ROLE OF PRIMARY CARE IS TO ASSURE
THAT SPECIALTY CARE IS MORE APPROPRIATE
AND, THEREFORE, MORE EFFECTIVE.
Source: Starfield et al, Health Aff 2005; W5:97-107
(http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1).
van Doorslaer et al, Health Econ 2004; 13:629-47;
Starfield 08/05
SP 3241
Use of Specialists in the US
• REFERRAL rates from primary care to
specialty care in the US are HIGH.
• Between 1/3 and 3/4 (depending on
the type of specialist) of visits to
specialists are for routine follow-up.
• The percentage of people SEEN BY a
specialist in a year is high, especially
in the presence of high morbidity
burden.
Sources: Forrest et al, BMJ 2002; 325:370-1. Valderas et al, Ann Fam Med 2008, in press.
Starfield 03/06
SP 3396
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
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.
Source: Weingarten et al, Arch Intern Med 2002; 162:527-32.
Starfield 09/04
04-141
SP
2963
The greater the co-morbidity, the greater
the chance of referral in individual visits.
The more common the condition in primary
care visits, the less the likelihood of referral,
even after controlling for a variety of patient
and disease characteristics.
When co-morbidity is very high, referral is
more likely, even in the presence of
common problems.
Source: Forrest & Reid, J Fam Pract 2001;50:427-32.
Starfield 01/09
RC 4119
How Frequently Do Specialists Take Care of
People with “Specialty” Conditions?
% of episodes
Cardiologists
36% of those with cardiac disease
Orthopedists
22% of of those with musculoskeletal disease
Neurologists
40% of those with nervous system disease
Factors other than age, gender, and overall “morbidity burden”
determine whether a patient will be seen by a specialist or not,
and how much it will cost. Episodes in which a specialist is
seen are more expensive.
Source: Spitzer, ACG Users Conference, 9/2000.
Starfield
Starfield10/00
2000
SP
00-078
1744
Expected Resource Use (Relative to Adult
Population Average) by Level of CoMorbidity, British Columbia, 1997-98
Acute conditions
only
Chronic condition
High impact chronic
condition
None
0.1
Low
0.4
Medium
1.2
High
3.3
Very
High
9.5
0.2
0.2
0.5
0.5
1.3
1.3
3.5
3.6
9.8
9.9
Thus, it is co-morbidity, rather than presence or impact of
chronic conditions, that generates resource use.
Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents
of British Columbia. Vancouver, BC: University of British Columbia, 2005.
Starfield 09/07
CM 3867 n
Management focused primarily on diseases
does not make sense for primary care.
The benefits of primary care (person-focused,
comprehensive, and coordinated) are greatest
for people with high morbidity burdens.
This is at least part of the reason why disease
management has not proven useful in
improving health. Even the chronic care model
will not be useful unless it is carried out in the
context of good primary care.
Sources: Mangione et al, Ann Intern Med 2006;145:107-16.
Tsai et al, Am J Manag Care 2005;11:478-88
Starfield 01/09
D 4108
Comprehensiveness in primary
care is necessary in order to
avoid unnecessary referrals to
specialists, especially in people
with co-morbidity.
Starfield 02/09
COMP 4148
Assessment of Specialty Care Orientation
• percentage of population seeing one or more
specialists in a year
• visits to specialists per person in a year
• percentage of patients seeing one or more
specialists in a year
• visits to specialists per patient per year
• percentage of patients referred in a year
• ability of patients to go directly to specialists for
new and/or re-visits)
ALL of the above are also relevant for the type of
specialist, and for the reason for visit.
Starfield 04/07
SP 3636
Proposed Benefits of
Subspecialization
•
•
•
•
•
•
•
•
Quicker potential access
Improved patient and/or practitioner satisfaction
Make primary care more intellectually rewarding
Reduced referrals to secondary care
Career development (circular reasoning!)
Improved communication with specialists*
Clinical benefits*
Financial benefits*
*No evidence to date
Source: based on Leese, Comprehensiveness v special interests: Family medicine should
encourage its clinicians to subspecialize. In Kennealy & Buetow. Ideological Debates in
Family Medicine. New York, NY: Nova Publishing, 2007.
Starfield 01/07
SP 3524
Evidence on the Impact of
Subspecialization
• Increases referrals without improving
outcomes
• Increases costs and administrative
challenges
• May improve patient’s view of access to care
• Practitioners may function more as
specialists than as primary care physicians.
Source: Starfield & Gervas, Comprehensiveness v special interests. Family medicine
should encourage its clinicians to specialize: Negative. In Kennealy & Buetow,
Ideological Debates in Family Medicine. New York, NY: Nova Publishing, 2007.
Starfield 01/07
SP 3549
Making More Efficient Use of
Specialists
• Consider when specialist referrals can be
avoided by direct consultation between the
primary care physician and the specialist,
without the patient having to be present.
• Develop a strong secondary (community) level
of care for diagnostic testing.
• Periodic specialist (secondary level) visits to
primary care, perhaps involving group visits
where appropriate.
Starfield 01/07
SP 3533
Questions Needing Answers
1. Is the greater use of diagnostic
technology among specialists only
because of higher prior probability of a
positive result, or is there some inherent
predisposition to using diagnostic tests
among specialty-oriented physicians?
Starfield 02/03
03-041
SP
2425
Questions Needing Answers
2. Is co-morbidity associated with more
hospitalizations for ambulatory care
sensitive conditions (ACSC) because
there is simply more pathology or
because medical care does a poor job
of detecting and treating co-morbidity?
3. Can we clearly specify what it is that
specialists can do that primary care
physicians can’t do?
Starfield 02/03
03-042
SP
2426
Questions Needing Answers
4. At what time during an episode of illness
should one refer to a specialist? How can
this appropriate time be measured?
5. Is there evidence for a threshold of
frequency such that something is too
rare for primary care physicians to
maintain competence?
6. Is it good (or bad) that the rich see
specialists more than the poor?
Starfield 02/03
03-043
SP
2427
Augmenting the Potential
of Primary Care:
Comprehensiveness
• Caring for all but uncommon conditions
Starfield 08/02
02-140 2166
COMP
Primary Care Orientation of
Health Systems: Rating Criteria
• Practice Characteristics
– First-contact
–
–
–
–
–
Longitudinality
Comprehensiveness
Coordination
Family-centeredness
Community orientation
Source: Starfield. Primary Care: Balancing Health Needs,
Services, and Technology. Oxford U. Press, 1998.
Starfield
Starfield11/02
11/02
PC
02-406
2367sc
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
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
Distribution of Reasons for
Referral: Badalona, Spain
Diabetes
24.4% (ophthalmology)
Local inflammation/mass
16.5% (dermatology)
10.7% (general surgery)
13.0% (dermatology)
11.5% (ophthalmology)
Molluscum contagiosum
Visual signs and symptoms
Lipoma
Benign/undefined skin
neoplasia
11.4% (general surgery)
10.8% (dermatology)
Auditory signs and symptoms 10.5% (ENT)
Notes:
1. More than one reason is common.
2. Although orthopedic referrals are the most common specialist
referrals, the percentage of reasons for any one is low.
Starfield 01/07
SP 3530
Condition-specific Analysis of Referral Rate by
Practice Prevalence for Selected Conditions
with Adequate Sample Size (n=65)
NOTE: The data are
from the 1989 to
1994 National
Ambulatory Medical
Care Surveys. Axes
are on the
logarithmic scale.
Medical conditions
are represented by
the circles, surgical
conditions by the
triangles, and other
conditions
(gynecologic and
psychosocial) by the
squares. EDC
denotes expanded
diagnosis clusters.
Source: Forrest & Reid, J Fam Pract 2001; 50:427-32.
Starfield 01/09
RC 4124
Average Number of Visits Per Year to Primary Care
and Specialists by Morbidity Burden, Co-morbid
Conditions, Managed Care Organizations, 1996
9
Mean Number of Visits
8
7
5.68
6
*
5
4.32
3.46
4
*
3
2
1
1.69
1.81
*
0.68
0
Low-medium
High
Very high
Morbidity Group
*p<.0001
Primary Care Physician
Based on data in Starfield et al, Ann Fam Med 2003; 1:8-14.
Specialist
Starfield 08/08
SP 4054 n
Average Number of Visits Per Year to Primary
Care and Specialists by Morbidity Burden,
Co-morbid Conditions, Medicare
8.95
9
*
Mean Number of Visits
8
6.57
7
6
5
3.9 *
4
3
2
2.12
4.32
* 1.8
1
0
Low-medium
High
Very high
Morbidity Group
*p<.0001
Primary Care Physician
Source: Starfield et al, Ann Fam Med 2005; 3:215-22.
Specialist
Starfield 08/08
SP 4055 n
Co-morbidity and Volume of
Visits to Primary Care Physicians
The number of visits to primary care
physicians for OTHER conditions is greater
than the number of visits to specialists for
OTHER conditions
AND
the number of visits to primary care physicians
for OTHER conditions is greater than the
number of visits for the index condition.
Starfield 04/01
01-062 1869
CMOS
Co-morbidity and Visits to
Specialists
For most common chronic conditions,
non-elderly people with a lot of comorbidity see specialists less than
primary care physicians for BOTH the
index and OTHER conditions.
For elderly patients with high and very
high co-morbidity, use of specialists (at
least in the US) is much greater.
Starfield 09/03
03-147 2530
CMOS
Co-morbidity: Conclusions about
Use and Type of Services
• Primary care providers are the major providers of
care BOTH for index and chronic conditions and
for OTHER conditions, in people with all degrees
of co-morbidity, EXCEPT for uncommon
conditions, e.g., diabetes in children.
• Disease case management by specialists in the
condition does NOT appear to be an appropriate
strategy. Co-morbidity is what drives the difference
in number of visits to both primary care physicians
and specialists.
Starfield 04/01
01-063 1870
CMOS