The Primacy of Primary Care
in Health Services Systems
Barbara Starfield, MD, MPH, FRCGP
May 2002
The Countries,
Mid-1990s
Australia
Belgium
Canada
Denmark
Finland
France
Germany
Japan
Netherlands
Spain
Sweden
United Kingdom
United States
Starfield
Reimbursement of Physicians**
Primary Care
Belgium
France
Germany
United States
Australia
Canada
Japan
Sweden
Denmark
Finland*
Netherlands
Spain
United Kingdom
1980s
F
F
F
F
1990s
F
F
F
F
Specialists
1980s
F
F
F
F
1990s
F
F
F
F
F
F
F
S
F
F
F
S
F
F
F
S
F
F
F
S
C/F
S/C
C/F
S
C
F/C
S/C
C/F
S
C/F
S/F
S
F
S
S
F
S
S
S
S
F=Fee-for-Service
C=Capitation
S=Salary
*but substantial
private sector feefor-service
** for those who
work in community
Starfield 2000
Are Specialists Limited to Hospital Practice?
Early-Mid 1990s
Belgium
France
Germany
United States
No
No
No
No
Australia
Canada
Japan
Sweden
No
No
No
No
Denmark
Finland*
Netherlands
Spain
United Kingdom
Yes
Yes
Yes
No
Yes
Starfield 2000
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
adapted from Starfield B. Primary Care:
Balancing Health Needs Services
& Technology, 1998 (Chapter 15)
Starfield
Primary Care Orientation of Health
Systems: Rating Criteria
• Practice Characteristics
–
–
–
–
–
–
First-Contact
Longitudinality
Comprehensiveness
Coordination
Family-centeredness
Community orientation
adapted from Starfield B. Primary Care:
Balancing Health Needs Services
& Technology, 1998 (Chapter 15)
Starfield
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
Starfield 2000
Practice Characteristics
(Rank*)
System and Practice 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*)
Starfield 11/00
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
Starfield 2000
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 10/00
Average Rankings* for Health Indicators in
Infancy, for Countries Grouped by Primary
Care Orientation
Low Birth
Weight
(1993)
Neonatal
Mortality
(1993)
9.5
7.8
Lowest
(Belgium, France,
Germany, US)
Middle
(Australia, Canada,
Japan, Sweden)
7.3
Highest
4.8
(Denmark, Finland,
Netherlands, Spain,
UK**)
5.3
5.9
Postneonatal
Infant
Mortality
Mortality
(1993)
(1996)
11.5
5.5
6.7
7.8
8.8
6.0
5.0
4.6
6.2
6.4
*Best level of health indicator is ranked 1; worst
is ranked 13, thus, lower average ranks indicate
better performance.
**England and Wales only
Starfield 04/01
Average Rankings for Health Indicators, YPLL (Total and
Suicide) in Countries Grouped by Primary Care Orientation
All Except Suicide
Female
Male
Lowest
9.5
(Belgium,
France,
Germany,
US)
Middle
3.8
(Australia,
Canada, Japan,
Sweden)
Highest
7.6
(Denmark,
Finland,
Netherlands,
Spain, UK)
Source: OECD Tapes, 1998
Suicide
Female Male
All Except External
Female
Male
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
Starfield 2000
Average Rankings for Health Indicators
for Countries Grouped by Primary Care Orientation:
World Health Report, 2000
Lowest
(Belgium, France,
Germany, US)
Middle*
(Australia, Canada,
Sweden, Japan)
Highest*
(Denmark, Finland,
Netherlands, Spain, UK)
DALEs
Child Survival
Equity
Overall
Health
16.3
22.5
36.3
4.8
16.5
26.0
11.0
16.0
DALE: Disability adjusted life expectancy (life lived in good health)
Child survival: survival to age 5, 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
15.8
15.2
29.1
31.6
Source: Calculated from
WHO, World Health Report
(Health Systems: Improving
Performance) 2000
Starfield 2000
Average Rankings* for Life Expectancy at
Ages 40, 65, and 80, for Countries Grouped
by Primary Care Orientation
Age 40
Female
Lowest
(Belgium, France,
Germany, US)
Middle
(Australia, Canada,
Japan, Sweden)
7.8
4.0
Highest
8.8
(Denmark, Finland,
Netherlands, Spain,
UK**)
Age 65
Age 80
Male Female Male
9.5
2.5
6.7
8.0
3.8
5.9
8.6
8.0
3.5
6.6
8.8
Female
Male
7.4
6.9
3.6
6.6
9.0
9.5
4.3
6.8
7.1
9.3
*Best level of health indicator is ranked 1; worst
is ranked 13, thus, lower average ranks indicate
better performance.
**England and Wales only
Starfield 04/01
Percentage of Individuals Who Smoke per Capita at
Ages 15 and Older, Early-Mid 1990s*
Belgium
France
Germany
United States
Australia
Canada
Japan
Sweden
Denmark
Finland
Netherlands
Spain
United Kingdom
*All countries 1992, except Canada (1991), Spain (1993)
Female
21.0
20.0
21.5
24.6
23.8
26.0
13.3
26.6
40.1
20.0
30.5
21.0
28.0
Male
31.0
38.0
36.8
28.6
28.2
26.0
60.4
25.2
45.9
33.0
42.9
44.0
29.0
Starfield 2000
Ranking of Countries by Income Inequality
Country
Earned Income
(90/20 ratio)
Disposable Income
(Gini)
Belgium
France
Germany
United States
5
10
7
11
3
8
6
13
Australia
Canada
Japan
Sweden
12
9
1
2
10
7
11
2
Denmark
Finland
Netherlands
Spain
United Kingdom
8
6
4
3
13
4
1
5
9
12
Starfield 2000
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
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 2000
Factors Related to In-hospital Standardized
Mortality, England (NHS Hospitals),
1991-2 to 1994-5
Regression Coefficient
% of cases admitted as emergency
0.58
# hospital doctors/100 hospital beds
-0.47
# GPs/100,000 population
-0.67
Standardized admission ratio
-0.15
% live discharges to home
1.61
% patients with co-morbidity
1.51
NHS facilities/100,000 population
-1.12
Source: Jarman, et al., BMJ, 1999
Starfield 2000
Major Determinants of Outcomes*:
50 US States
Specialty Physicians:
Primary Care Physicians:
Hospital Beds:
Education:
Income:
Unemployment:
Urban:
Pollution:
Life Style:
Minority:
More: all outcomes worse
Fewer: all outcomes worse
More: higher total, heart disease, and neonatal mortality
No relationship
Lower: higher heart and cancer mortality
Higher: higher total mortality, lower life span, more low
birthweight
Lower mortality (all), longer life span
Higher total mortality
Worse: higher total and cancer mortality, lower life span
Higher total mortality, neonatal mortality, low
birthweight, lower life span
Note: All variables are ecologic, not individual
*Overall mortality; mortality from heart disease, mortality from cancer, neonatal mortality, life span,
low birthweight.
Source: Shi, 1994
Starfield 1999
Rates of Avoidable Adult Hospitalization for 6
Conditions and Family Physicians-Internists per
10,000 Population
Source: Parchman & Culler, 1994
Starfield 1999
Rates of Avoidable Pediatric Hospitalization for Diabetes
Mellitus and Pneumonia and Family PhysiciansPediatrician Physicians per 10,000 Population
Source: Parchman & Culler, 1994
Starfield 1999
Adjusted Odds Ratios for Severe, Uncontrolled
Hypertension According to Various Risk Factors*
Risk Factor
No primary care
No medical insurance
Noncompliance with antihypertensive
regimen†
One or more alcohol-related problems
Illicit drug use‡
No. of Patients
with Complete
Data
Adjusted
Odds Ratio
(95% CI)
P Value
204
204
199
4.4 (2.2-8.9)
2.2(1.0-4.6)
2.0 (1.5-2.7)
<0.001
0.04
<0.001
204
204
2.2 (0.8-6.3)
1.3 (0.5-3.6)
0.14
0.60
*Adjustment was made in each model for age, sex, race or ethnic group, educational level, and current smoking status, but not for
other risk factors. Odds ratios are expressed as the risk of severe, uncontrolled hypertension for a patient with the risk without it.
CI denotes confidence interval.
†Categorized on a five-point scale.
‡In the past year.
Source: Shea et al 1992
Starfield 1999
Health Care Expenditures and
Mortality 5 Year Followup:
United States, 1987-92
• Adults (age 25 and older) with a primary
care physician rather than a specialist
as their personal physician
• had 33% lower cost of care
• were 19% less likely to die (after controlling for
age, gender, income, insurance, smoking,
perceived health (SF-36) and 11 major health
conditions)
Source: Franks & Fiscella, 1998
Starfield 1999
Primary Care Reform, 1984-90 to 1994-96
Percent Decline in Mortality - Various Causes, Barcelona, Spain
45
E = 40
40
M = 38
M = 35
L = 35
35
% Decline
30
25
E = 23
20
15
10
L=6
5
0
Hypertension
Source: Villalbi, et al., 1999
Perinatal
E = Early Implementation
M = Later Implementation
L = Late Implementation
Starfield 2000
State Level Analysis:
Primary Care and Life Expectancy
78
Life Expectancy
77
76
75
74
73
72
.ND
.
E SD
.N.ME
ID
..NH
.OR
.
AZ
RI
.IA .UT .ID .TN ...NM.
.FL .MT .NJ
.NY
.MI.TX . .DE .AR WI. KYKS .PA
.AL WV
.NC .VA.
IL
.MS
.
.AK
.GA . NV
SC
71
4.00
.
.MACT..WAMN
. .
. HI
CA
.MD
R=.54
LA
P<.05
4.50
5.00
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.
Shi et al. Income, Inequality, Primary Care and Health Indicators. Journal of Family Practice. April 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**
Infant
Mortality
.35*
-.36**
-.29*
Income Inequality
(Robin Hood Index)
-.33*
Primary Care
Physicians
-.37**
Life
Expectancy
*p<.05; **p<.01.
.41**
.58**
-.17
Low
Birthweight
Source: Shi, Starfield, Kennedy, Kawachi, JFP 1999
Path Coefficients for the Effects of Income Inequality and
Primary Care on Health Outcome: 50 US States, 1990
Life Expectancy
Total
Mortality
.39**
Neonatal
Mortality
.40**
-.35**
-.38**
Income Inequality
(GINI COEFFICIENT)
-.18
-.33*
Primary Care
Physicians
.16
Stroke
Mortality
-.38**
.42**
.18
-.33*
Postneonatal
Mortality
Life Expectancy
*p<.05; **p<.01.
Source: Shi, Starfield, Kennedy, Kawachi, JFP 1999
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, IJHS, 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, IJHS, 2000
Starfield 2000
Reductions* in Inequality in Health by
Primary Care: Stroke Mortality,
50 US States, 1990
Areas with low income inequality
High primary care resources
Low primary care resources
1.3% decrease in mortality
2.3% increase in mortality
Areas with high income inequality
High primary care resources
Low primary care resources
2.3% decrease in mortality
1.1% increase in mortality
*compared with population mean
Based on data in Shi & Starfield, IJHS, 2000
Starfield 2000
Primary Care Practice Characteristics:
Evidence-Based
• 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 1999
Primary Care and Equity:
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 2000
Ranking on 16 Health Indicators
(Best to Worst), Mid 1990s
Japan
Sweden
Canada
France
Australia
Spain
Finland
Netherlands
United Kingdom
Denmark
Belgium
United States
Germany
Starfield 1999
Ranking, World Health Report (13 Countries)
Country
Japan
Australia
France
Sweden
Spain
Canada
Netherlands
United Kingdom
Belgium
Finland
Germany
United States
Denmark
DALE
1
2
3
4
5
6
7
8
9
10
11
12
13
Source: World Health Report, 2000, Annex tables 9, 5
Child Survival
Equity
2
6
4
12
3
7
5
1
10
11
8
13
9
Health System
Attainment
1
7
3
2
11
4
5
6
8
13
9
10
12
Starfield 2000
Health System Attainment,
World Health Organization
Components and Weighting
Level of health (DALEs)
25%
Distribution of health
(equity of child survival)
25%
Level of responsiveness of system
12.5%
Distribution of responsiveness
12.5%
Fairness of financial contribution
25%
Source: World Health Report, 2000, Annex table 9
Starfield 2000