The Primacy of Primary Care
in Health Services Systems
Barbara Starfield,
MD, MPH
November 2002
The Countries, Mid-1990s
Australia
Belgium
Canada
Denmark
Finland
France
Germany
Japan
Netherlands
Spain
Sweden
United Kingdom
United States
Starfield
Reimbursement of Physicians**
Belgium
France
Germany
United States
Primary Care
1980s 1990s
F
F
F
F
F
F
F
F
Specialists
1980s 1990s
F
F
F
F
F
F
F
F
Australia
Canada
Japan
Sweden
F
F
F
S
F
F
F
S
F
F
F
S
F
F
F
S
Denmark
Finland*
Netherlands
Spain
United Kingdom
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
Starfield 2000
Are Specialists Limited to Hospital Practice?
Early-Mid 1990s
Belgium
France
Germany
United States
Australia
Canada
Japan
Sweden
Denmark
Finland
Netherlands
Spain
United Kingdom
No
No
No
No
No
No
No
No
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
Source: Starfield, 1998.
Starfield
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
1980s
Belgium
France*
Germany
United States
0.8
0.5
0.2
1990s
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
1.5
1.5
1.5
1.7
1.7
1.5
1.5
1.4
1.9
Denmark
Finland
Netherlands
Spain*
United Kingdom
Starfield 10/02
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
1,5
NTH
SP
1
FIN
CAN
AUS
SWE
GER
0,5
0
1000
JAP
BEL
1500
US
FR
2000
2500
3000
3500
Per Capita Health Care Expenditures
4000
Primary Care Orientation
and
Population Health Status
Starfield 10/02
Average Rankings* for Health Indicators
in Infancy, for Countries Grouped by
Primary Care Orientation
Lowest
(Belgium, France,
Germany, US)
Middle
(Australia,
Canada, Japan,
Sweden)
Highest
(Denmark,
Finland,
Netherlands,
Low Birth
Weight
(1993)
Neonatal
Mortality
(1993)
9.5
7.8
7.3
5.3
5.9
4.8
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
Starfield 04/01
Average Rankings for Health Indicators, YPLL (Total and
Suicide) in Countries Grouped by Primary Care Orientation
All Except Suicide
Female
Male
Suicide
Female
Male
Lowest
9.5
10.8
7.3
8.3
(Belgium,
France,
Germany,
US)
Middle
3.8
2.8
7.0
7.3
(Australia,
Canada, Japan,
Sweden)
Highest
7.6
7.4
6.8
5.8
(Denmark,
Finland,
Netherlands,
Spain, UK)
Source: OECD, 1998.
All Except External
Female
Male
8.8
10.8
3.8
3.5
8.2
7.0
Starfield 2000
Average Rankings* for Life Expectancy at
Ages 40, 65, and 80, for Countries
Grouped by Primary Care Orientation
Lowest
Age 40
Age 65
Age 80
Female Male Female Male Female Male
7.8
9.5
8.0
8.0
7.4
6.9
(Belgium, France,
Germany, US)
Middle
4.0
(Australia, Canada,
Japan, Sweden)
Highest
2.5
6.7
8.8
3.8
5.9
8.6
8.8
3.5
6.6
3.6
6.6
9.0
9.5
4.3
6.8
7.1
9.3
(Denmark, Finland,
Netherlands, Spain,
UK**)
Starfield 04/01
Average Rankings for World Health Organization
Health Indicators for Countries Grouped
by Primary Care Orientation
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 2, 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, 2000.
Starfield 10/02
Percentage of Individuals Who Smoke per Capita at
Ages 15 and Older, Early-Mid 1990s*
Female
21.0
20.0
21.5
24.6
Male
31.0
38.0
36.8
28.6
Australia
Canada
Japan
Sweden
23.8
26.0
13.3
26.6
28.2
26.0
60.4
25.2
Denmark
Finland
Netherlands
Spain
United Kingdom
40.1
20.0
30.5
21.0
28.0
45.9
33.0
42.9
44.0
29.0
Belgium
France
Germany
United States
*All countries 1992, except Canada (1991), Spain (1993)
Ranking of Countries by Income Inequality
Country
Belgium
France
Germany
United States
Earned Income Disposable Income
(90/20 ratio)
(Gini)
5
3
10
8
7
6
11
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
Primary Care Score and Health Outcomes
Health Outcome
All-cause mortality
Association with Primary
Care Score*
In Males
In Females

Life expectancy

Infant Mortality Rate

PYLL (all causes)


PYLL (pneumonia & influenza)


PYLL (asthma & bronchitis)


PYLL (cerebrovascular disease)


PYLL (heart disease)


Source: Macinko et al., 2002.
Starfield 06/02
Primary Care Score and Premature
Mortality in 18 OECD Countries
10000
PYLL
Low PC Countries*
5000
All Countries*
High PC Countries*
0
1970
1980
1990
Year
Source: Macinko et al., 2002.
2000
Starfield 06/02
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., 1999.
Starfield 2000
Rates of Avoidable Adult Hospitalization
for 6 Conditions and Family Physicians
per 10,000 Population
Source: Parchman & Culler, 1994.
Starfield 10/02
Rates of Avoidable Pediatric Hospitalization for Diabetes
Mellitus and Pneumonia and Family Physicians
per 10,000 Population
Source: Parchman & Culler, 1994.
Starfield 10/02
Physician Supply and Odds Ratios*
of Diagnosis of Late-Stage
Colorectal Cancer
Primary care physicians
Urban Non-urban
0.92**
0.96
Specialty physicians
1.12**
1.02
*change in odds of late stage diagnosis with each 10
percentile increase in supply of physicians
**significant at p<.01
Source: Roetzheim et al., 1999.
Starfield 10/02
Adjusted Odds Ratios for Severe, Uncontrolled
Hypertension According to Various Risk Factors*
No. of Patients Adjusted
with Complete Odds Ratio
Risk Factor
No primary care
No medical insurance
Noncompliance with antihypertensive
regimen†
One or more alcohol-related problems
Illicit drug use‡
Data
(95% CI)
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
P Value
†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
E = 40
M = 38
M = 35
L = 35
% Decline
45
40
35
30
25
20
15
10
5
0
E = 23
L=6
Hypertension
Perinatal
E = Early Implementation
M = Later Implementation
L = Late Implementation
Source: Villalbi et al., 1999.
Starfield 2000
Major Determinants of Outcomes*:
50 US States
Specialty Physicians:
More: all outcomes worse
Primary Care Physicians: Fewer: all outcomes worse
Hospital Beds:
More: higher total, heart disease,
and neonatal mortality
Education:
Income:
Unemployment:
Urban:
Pollution:
Life Style:
Minority:
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
State Level Analysis:
Primary Care and Life Expectancy
78
Life Expectancy
77
.
. E SD .
N
.
. ME . NH
.
.
AZ
RI
. IA .UT ID
.
NM
. . MT . NJ
.
. TN
.
FL
. . TX . . AR WI. KS . PA
MI
. WV DE
.
. NC KY . VA
. IL
. MS AL
.
. AK
. GA NV
. SC
ID
76
75
74
73
72
.
.
. CT . .WAMN
. MA
. CA
. ND
. OR
HI
. NY
.
MD
R=.54
LA
P<.05
71
4.00
4.50
5.00
5.50
6.00
6.50
7.00
Primary Care Physicians/10,000 Population
PC physicians/population positively associated
with longer life expectancy.
Source: Shi et al., 1999.
Starfield 03/02
7.50
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
Source: Shi et al., 1999.
.41**
.58**
-.17
*p<.05; **p<.01.
Low
Birthweight
Starfield
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
Source: Shi et al., 1999.
*p<.05; **p<.01.
Starfield
Does Primary Care Reduce
Disparities in Health across
Population Subgroups?
Starfield 10/02
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
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, 2000.
Starfield 2000
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
Primary Care Practice Characteristics:
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 1999
Primary Care Practice Characteristics:
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 1999
Conclusions
Both international comparisons and
studies within countries document the
beneficial impact of primary care on
effectiveness (health outcomes), on
efficiency (lower costs), and on equity of
health outcomes (reducing disparities
across population subgroups).
Health policy should be directed toward
strengthening the primary care orientation
of health systems.