Primary Care Versus
Specialist Physician Supply
The variation in numbers (per
population) of neonatologists does
not vary with measures of need
(very low birth weight ratios); there
is no relationship between the
supply of neonatal resources and
infant mortality, and increases in
the supply of neonatologists
beyond a moderate level confer no
additional benefit.
The Regional Primary Care and Specialty
Physician Supply and Odds of Late-stage
Diagnosis of Colorectal Cancer
1.6
1.4
1
0.8
0.6
0.4
0.2
0
10
20
30
40
50
60
70
80
90
Percentiles
Primary Care
Specialists
100
Odds Ratios
1.2
Early detection of breast cancer is
greater when the supply of primary
care physicians is higher. Each tenth
percentile increase in primary care
physician supply is associated with
a statistically significant 4%
increase in the likelihood of EARLY
(rather than late) stage diagnosis.
For cervical cancer, rates of
incidence of advanced stage
presentation are lower in areas
that are well-supplied with
family physicians, but there is
no advantage of having a
greater supply of specialist
physicians, either in total or for
obstetrician/gynecologists.
Melanoma is identified at an earlier
stage in areas where the supply of
family physicians is high, both in
urban areas and non-urban areas.
The same is the case for
dermatologists, but the relationship
is not statistically significant, and
there is no relationship of early
detection with the supply of other
specialists.
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.
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
birth weight
Lower mortality (all), longer life span
Higher total mortality
Worse: higher total and cancer mortality, lower life span
Higher total mortality, neonatal mortality, low
birth weight, lower life span
Note: All variables are ecologic, not individual.
*Overall mortality; mortality from heart disease, mortality from cancer,
neonatal mortality, life span, low birth weight.
• 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)
We know that
1. Inappropriate referral to specialists leads to
greater frequency of tests than appropriate
referrals to specialists.
2. Inappropriate referrals to specialists leads to
poorer outcomes than appropriate referrals.
3. The socially advantaged have higher rates of
visits to specialists than the socially
disadvantaged.
4. Although greater primary care physician
supply is associated with better health in
populations, greater specialist supply is not
generally associated with better health
outcomes.
Does Primary Care
Reduce Inequity in
Health?
Equity in health is the absence
of systematic and potentially
remediable differences in one
or more aspects of health
across population groups
defined geographically,
demographically, or socially.
In state-level analyses controlled for
demographic and socioeconomic variables, a 20%
increase in the supply of primary care physicians
(one more per 10,000) is associated with a
3.3% lower age-adjusted mortality rate among
African-American population
2.0% lower age-adjusted mortality rate among
white population
That is, greater primary care resources are even
more beneficial to disadvantaged (AfricanAmerican) populations than to the majority
(white) population.
US urban infants
Geographic area
Low Birth Weight among US Rural, Urban, and
Primary Care Health Center Infants
8.8
Urban health center infants
7.5
US rural infants
6.8
6.0
Rural health center infants
10.4
African American urban health center infants
13.0
African American rural infants
7.4
African American rural health center infants
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Racial composition
13.6
African American urban infants
Association of Primary Care with Reduced
Racial Disparities in Healthy Life
Fraction of Healthy Life
White
0.88
0.86
0.84
0.82
0.80
0.78
0.76
0.74
0.72
0.70
Black
Hispanic
*
Other
*
*P<.05
*
CHC
NHIS
Odds Ratios for Poor Mental Health Status by
Adequacy of Primary Care in Different
Population Groups, US, 1998-1999
4.5
4.0
3.5
3.0
2.5
2.70
2.12
2.19
2.23 2.37 2.29
2.0
1.45
1.5
1.21 1.33
1.0
0.5
0.0
Without consideration
of primary care
White poverty
Considering primary
care
Black poverty
Controlling for
sociodemographic
characteristics
Hispanic poverty
Odds Ratios for Poor Physical Health Status by
Adequacy of Primary Care, in Different
Population Groups, US, 1998-1999
4.5
3.90
4.0
3.5
3.0
3.17
2.68
2.77 2.89
3.06
2.5
2.0
1.54
1.5
1.66
1.36
1.0
0.5
0.0
Without consideration
of primary care
White poverty
Considering primary
care
Black poverty
Controlling for
sociodemographic
characteristics
Hispanic poverty
Reductions* in Inequality in Health by
Primary Care: Postneonatal Mortality,
50 US States, 1990
Areas with low income inequality
(mostly homogeneous high income areas)
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
Reductions* in Inequality in Health by
Primary Care: Stroke Mortality,
50 US States, 1990
Areas with low income inequality
(mostly homogeneous high income areas)
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
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 (mostly
homogeneous high income areas)
– 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
Path Coefficients for the Effects of Income Inequality and
Primary Care on Health Outcome (50 US States, 1990)
Total
Mortality
.42**
-.36**
Infant
Mortality
.35*
-.29*
Income Inequality
(Robin Hood Index)
-.33*
Primary Care
Physicians
-.37**
Life
Expectancy
.41**
*p<.05; **p<.01.
.58**
-.17
Low Birth
Weight
Primary Care Reform, 1984-90 to 1994-96,
Percent Decline in Mortality - Various
Causes, Barcelona, Spain
45
% Decline
40
35
E = 40
M = 38
M = 35
L = 35
30
E = 23
25
20
15
10
L=6
5
0
Hypertension E = Early Implementation Perinatal
M = Later Implementation
L = Late Implementation
Does Primary Care Reduce
Inequity in Health in Developing
Countries?
So far, the evidence for the benefits of
primary care has come from industrialized
countries. What about developing
countries? Although there have been very
few studies of this subject in developing
countries, the conclusion is the same:
better primary health care, more equity in
health services and health outcomes.
In 7 African countries
• The highest 1/5 of the population
receives well over twice as much
financial benefit from overall government
health spending (30% vs 12%).
• For primary care, the poor/rich benefit
ratio is much lower (23% vs 15%).
“From an equity perspective, primary
care represents a clear step in the right
direction.”
Impact of a Primary Care Oriented
Approach in Bolivia, Early 1990s
Reformed
Areas
Adjacent Areas
(Comparison)
National
Data
Vaccinations complete
78%
8%
21%
3+ growth monitorings
80%
8%
NA
Infant
75
117
116*
1 year
19
58
NA
2-4 years
4
11
NA
1-4 years
7
22
16*
Age-specific mortality
*Rates for children whose mothers have less
than 5 years of education
Share of Public Spending on Health among
Countries with Similar GNP per Capita But Very
Disparate Child Survival (to Age 5) Rates, 1995
Ratio*: percent of expenditures for health from the government to
poorest 20% vs. richest 20% of population
High child survival
Low child survival
Additional children
lost per 1000
Sri Lanka
1.1
Ivory Coast
0.3
150
Malaysia
2.6
Brazil
0.4
45
Costa Rica
2.1
South Africa
0.9
55
Jamaica
3.3
Ecuador
0.2
25
Nicaragua
1.0
India
0.3
50
Egypt
0.6
Ivory Coast
0.3
100
*Ratios of one or more signify a greater share of government
expenditures to poorest segment of population.
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
Conclusion (1)
Virchow said that medicine is a social science
and politics is medicine on a grand scale.
We now know that it is primary health care
that is responsible for improved health and
for more equitable distributions of health.
Along with improved social and
environmental conditions as a result of public
health and social policies, primary care is an
important aspect of policy to achieve
effectiveness, efficacy, and equity in health
services.
Conclusion (2)
Although socioeconomic factors
undoubtedly influence health, health
services are a highly policy-relevant
influence because their effect is clear
and relatively rapid, particularly
concerning prevention of the
progression of illness and effects of
injury, especially at younger ages.