• 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 Starfield 01/09 COMP 4117 “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)
  • 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 Starfield 11/06 EQ 3500 n 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 ** Resource Allocation (Score) Progressive Financing* Cost Sharing Compre- 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
  • Criteria for Comprehensiveness Starfield 10/07 COMP 3891 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, work-related 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.
  • 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. Starfield 09/07 CMOS 3854 *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.
  • 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. 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):184-197 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf). Starfield 09/04 04-145 (Data controlled for sociodemographic characteristics, co-morbidity, and severity of illness) SP 2964 Starfield 09/04 SP 2964
  • Royal College of Physicians and Surgeons Task Force to Review Fundamental Issues in Specialty Education Starfield 01/09 SP 4085 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
  • 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) Starfield 01/07 COMP 3538 Sources: Rivo et al, JAMA 1994; 271:1499-1504. Boerma et al, Br J Gen Pract 1997; 47:481-6.
  • Comprehensiveness in Primary Care Starfield 03/08 COMP 4008 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?
  • 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. Starfield 01/07 COMP 3537 Source: Bindman et al, BMJ 2007; 334:1261-6.
  • 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 Starfield 04/04 COMP 2817
  • Primary Care Oriented Health Services Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/08 HS 4139 n
  • The Health Services System: Comprehensiveness Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 1999 99-014 Starfield 1999 HS 1441
  • PCAT: Comprehensiveness Subdomains Services available Services provided (received) Starfield 01/02 02-022 Starfield 01/02 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 1996 96-24 Starfield 05/96 PCM 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. Family planning or birth control methods Counseling for mental health problems Sewing up a cut that needs stitches Vision screening Starfield 01/02 02-027 Starfield 01/02 PCM 2052 *Examples
  • PCAT: Comprehensiveness (Services Provided*) In visits to your PCP, are any of the following things discussed with you? Advice about healthy foods and unhealthy foods Ways to handle family conflicts that may arise from time to time Advice about appropriate exercise for you Checking on and discussing the medications you are taking Starfield 01/02 02-028 Starfield 01/02 PCM 2053 *Examples
  • 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 Starfield 01/09 SP 4118 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.
  • We know that Inappropriate referrals to specialists lead to greater frequency of tests and more false positive results than appropriate referrals to specialists. Inappropriate referrals to specialists lead to poorer outcomes than appropriate referrals. The socially advantaged have higher rates of visits to specialists than the socially disadvantaged. The more the training of MDs, the more the referrals. 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 A MAJOR ROLE OF PRIMARY CARE IS TO ASSURE THAT SPECIALTY CARE IS MORE APPROPRIATE AND, THEREFORE, MORE EFFECTIVE.
  • 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. Starfield 03/06 SP 3396 Sources: Forrest et al, BMJ 2002; 325:370-1. Valderas et al, Ann Fam Med 2008, in press.
  • Percentage of People Seeing at Least One Specialist in a Year Starfield 01/07 SP 3529 n 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. US 40% of total population; 54% of patients (users) Canada (Ontario) 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)
  • 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. Starfield 09/04 04-141 Source: Weingarten et al, Arch Intern Med 2002; 162:527-32. Starfield 09/04 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. Starfield 01/09 RC 4119 Source: Forrest & Reid, J Fam Pract 2001;50:427-32.
  • % 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 2000 00-078 How Frequently Do Specialists Take Care of People with “Specialty” Conditions? Starfield 10/00 SP 1744
  • Expected Resource Use (Relative to Adult Population Average) by Level of Co-Morbidity, British Columbia, 1997-98 Starfield 09/07 CM 3867 n Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005. Thus, it is co-morbidity, rather than presence or impact of chronic conditions, that generates resource use. None Low Medium High Very High Acute conditions only 0.1 0.4 1.2 3.3 9.5 Chronic condition 0.2 0.5 1.3 3.5 9.8 High impact chronic condition 0.2 0.5 1.3 3.6 9.9
  • 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. Starfield 01/09 D 4108 Sources: Mangione et al, Ann Intern Med 2006;145:107-16. Tsai et al, Am J Manag Care 2005;11:478-88
  • 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) Starfield 04/07 SP 3636 ALL of the above are also relevant for the type of specialist, and for the reason for visit.
  • 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* Starfield 01/07 SP 3524 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. *No evidence to date
  • 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. Starfield 01/07 SP 3549 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.
  • 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 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 Starfield 02/03 SP 2425
  • Questions Needing Answers 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? Can we clearly specify what it is that specialists can do that primary care physicians can’t do? Starfield 02/03 03-042 Starfield 02/03 SP 2426
  • Questions Needing Answers At what time during an episode of illness should one refer to a specialist? How can this appropriate time be measured? Is there evidence for a threshold of frequency such that something is too rare for primary care physicians to maintain competence? Is it good (or bad) that the rich see specialists more than the poor? Starfield 02/03 03-043 Starfield 02/03 SP 2427
  • Augmenting the Potential of Primary Care: Comprehensiveness Caring for all but uncommon conditions Starfield 08/02 02-140 Starfield 08/02 COMP 2166
  • Primary Care Orientation of Health Systems: Rating Criteria Practice Characteristics First-contact Longitudinality Comprehensiveness Coordination Family-centeredness Community orientation Starfield 11/02 02-406 sc Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 11/02 PC 2367 n
  • Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s Starfield 07/07 ICTC 3758 n 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
  • *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. System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s Starfield 03/05 ICTC 3099 n
  • Distribution of Reasons for Referral: Badalona, Spain Starfield 01/07 SP 3530 Notes: More than one reason is common. Although orthopedic referrals are the most common specialist referrals, the percentage of reasons for any one is low. Diabetes 24.4% (ophthalmology) Local inflammation/mass 16.5% (dermatology) 10.7% (general surgery) Molluscum contagiosum 13.0% (dermatology) Visual signs and symptoms 11.5% (ophthalmology) Lipoma 11.4% (general surgery) Benign/undefined skin neoplasia 10.8% (dermatology) Auditory signs and symptoms 10.5% (ENT)
  • Condition-specific Analysis of Referral Rate by Practice Prevalence for Selected Conditions with Adequate Sample Size (n=65) Source: Forrest & Reid, J Fam Pract 2001; 50:427-32. Starfield 01/09 RC 4124 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.
  • Average Number of Visits Per Year to Primary Care and Specialists by Morbidity Burden, Co-morbid Conditions, Managed Care Organizations, 1996 *p
  • Average Number of Visits Per Year to Primary Care and Specialists by Morbidity Burden, Co-morbid Conditions, Medicare *p
  • Co-morbidity and Volume of Visits to Primary Care Physicians Starfield 04/01 01-062 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 CMOS 1869
  • Co-morbidity and Visits to Specialists Starfield 09/03 03-147 For most common chronic conditions, non-elderly people with a lot of co-morbidity 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 CMOS 2530
  • 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 Starfield 04/01 CMOS 1870 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * l * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * This slide shows the four main policy characteristics related to effectiveness and equity of primary health care services: distribution of resources according to extent and type of health needs, progressivity of financing, degree of cost sharing, and breadth of services provided in primary care. Scores range from zero (0), where the policy characteristic is absent, to a score of 1, where the characteristic is present but poorly developed, to a score of 2, where the characteristic is well developed. Belgium, France, Germany, and the US have weak primary health care systems; Denmark, Finland, The Netherlands, Spain, and the UK have strong primary healthcare; and Australia, Canada, Japan, and Sweden are in-between. With few exceptions, countries with equity-focused health policy are countries with strong primary care; countries with weak policy characteristics have weak primary care health systems. Sources: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. van Doorslaer E, Wagstaff A, Rutten F. Equity in the Finance and Delivery of Health Care: An International Perspective. New York: Oxford University Press, 1993. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Sources: Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):201-218. Boerma WGW, van der Zee J, Fleming DM. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997; 47(421):481-486. Boerma WGW, Groenewegen PP, van der Zee J. General practice in urban and rural Europe: the range of curative services. Soc Sci Med 1998; 47:445-53. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * Source: 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 forthcoming. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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 ). 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * Sources: Rivo ML, Saultz JW, Wartman SA, DeWitt TG. Defining the generalist physician's training. JAMA 1994; 271(19):1499-1504. Boerma WG, van der ZJ, Fleming DM. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997; 47(421):481-486. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * Source: Bindman AB, Forrest CB, Britt H, Crampton P, Majeed A. Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys. BMJ 2007; 334(7606):1261-1266. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 new slides * * Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. This diagram contains all of the elements of health services systems, highlighting those that are important to the achievement of primary care. These essential functions of primary care require attention to the particular elements of capacity, to one special element of provider behavior, and two elements reflecting the activities of patients and populations. Although many other elements of capacity and performance are involved in primary care, the identified elements act as the essential enabler to achieve first contact care, person-focused care over time, comprehensiveness of care, and coordination of care.  Once these functions are achieved, ensuing behaviors are dealt with as elements of the quality of care that is provided when problems are recognized as needing attention. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1). van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilisation in Europe. Health Econ 2004; 13(7):629-647. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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 2008; in press. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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-Y, Lemke KW, Weiner JP. Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. Submitted 2008. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians' specialty referral decisions. J Fam Pract 2001;50:427-32. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Spitzer M. Personal communication. ACG Users Conference, September 2000. 09 NZ comprehensiveness Feb * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * These data, from one province in Canada, show that there is little difference in resource use for people with only acute conditions, people with any chronic conditions, or people with only serious chronic conditions when the morbidity burden is the same. However, increasingly higher morbidity burden (i.e., more multi-morbidity) is associated with progressively higher resource use, and the increase is the same regardless of the type of diagnosis (acute, chronic, major chronic). Chronic conditions alone do not, by themselves, imply high need for resources. Source: Broemeling A-M, Watson D, Black C. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005. 09 NZ comprehensiveness Feb * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * Sources: Mangione CM, Gerzoff RB, Williamson DF, et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006;145:107-16. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005;11:478-88. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Each country was also rated 0, 1, or 2 with regard to its achievement of the cardinal features of primary care practice. A score of 0 indicates poor achievement of the feature; a score of 1 indicates intermediate achievement, and a score of 2 indicates high achievement of the feature. First contact is the seeking of care for each newly occurring problem or need from a primary care practitioner rather than a specialist. Longitudinality is person-focused (not disease-focused) relationships over time with the primary care source. Comprehensiveness is the provision, by the primary care source, of services for all health-related needs except those too uncommon in the population for competence to be maintained. Coordination is the integration of care by the primary care source when services outside of primary are required. Two related characteristics were also rated. Family centeredness is the extent to which services are provided in a family context. Community orientation is the extent to which data on community health needs are taken into account in planning for primary care services. Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * During the 1990s, two successive international comparisons involved rating different countries on the strength of primary care within the country. Ratings of primary health care were obtained by rating 6 (and 9 in the later study) characteristics of policy in each country: efforts to distribute resources according to where they were most needed; maintaining low or no cost-sharing; financial access controlled or regulated by government; the type of primary care practitioner (family physician or a mixture of types including also general internists and general pediatricians); and the presence of patient lists by primary care practices. In the second study, the following were added: low or no copayments for primary care; strength of academic departments of family medicine; the presence of patient lists by primary care practices; and 24-hour availability of primary care practices. Extent of achievement of the clinical features of first contact care, person-focused care over time, comprehensiveness (breadth) of services, coordination of care, family centeredness, and community orientation were also rated. Each characteristic was rated on a scale of 0 to 2, then all scores were averaged to obtain a systems score, a practice score and a combined overall primary care score. Eleven, and then 13 industrialized countries were compared; this comparison led to three groups of countries: those with low scores, those with intermediate scores, and those with high scores. These three groupings were unchanged over the decade between the two studies. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * The primary care score has two parts: the first reflects the strength of primary health care (that is, policies oriented towards primary care), and the second reflects the practice of primary care at the clinical level. In this chart, the countries are ranked by each of their two sub-scores. The country with the best sub-score is ranked #1, and the one with the worst sub-score is ranked #13. The better the policies (systems rankings), the better the practices, indicating the importance of governmental policy to good practice. Based on data in Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):201-218. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians' specialty referral decisions. J Fam Pract 2001; 50(5):427-432. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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 co-morbidity (diagnoses additional to any specified main diagnosis), it is the visits for co-morbid 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * For the elderly in the United States, the additional visits to specialists in a year resulting from co-morbid 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * *
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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. - PowerPoint PPT Presentation
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  • 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 Starfield 01/09 COMP 4117 “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)
  • 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 Starfield 11/06 EQ 3500 n 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 ** Resource Allocation (Score) Progressive Financing* Cost Sharing Compre- 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
  • Criteria for Comprehensiveness Starfield 10/07 COMP 3891 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, work-related 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.
  • 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. Starfield 09/07 CMOS 3854 *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.
  • 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. 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):184-197 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf). Starfield 09/04 04-145 (Data controlled for sociodemographic characteristics, co-morbidity, and severity of illness) SP 2964 Starfield 09/04 SP 2964
  • Royal College of Physicians and Surgeons Task Force to Review Fundamental Issues in Specialty Education Starfield 01/09 SP 4085 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
  • 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) Starfield 01/07 COMP 3538 Sources: Rivo et al, JAMA 1994; 271:1499-1504. Boerma et al, Br J Gen Pract 1997; 47:481-6.
  • Comprehensiveness in Primary Care Starfield 03/08 COMP 4008 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?
  • 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. Starfield 01/07 COMP 3537 Source: Bindman et al, BMJ 2007; 334:1261-6.
  • 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 Starfield 04/04 COMP 2817
  • Primary Care Oriented Health Services Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/08 HS 4139 n
  • The Health Services System: Comprehensiveness Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 1999 99-014 Starfield 1999 HS 1441
  • PCAT: Comprehensiveness Subdomains Services available Services provided (received) Starfield 01/02 02-022 Starfield 01/02 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 1996 96-24 Starfield 05/96 PCM 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. Family planning or birth control methods Counseling for mental health problems Sewing up a cut that needs stitches Vision screening Starfield 01/02 02-027 Starfield 01/02 PCM 2052 *Examples
  • PCAT: Comprehensiveness (Services Provided*) In visits to your PCP, are any of the following things discussed with you? Advice about healthy foods and unhealthy foods Ways to handle family conflicts that may arise from time to time Advice about appropriate exercise for you Checking on and discussing the medications you are taking Starfield 01/02 02-028 Starfield 01/02 PCM 2053 *Examples
  • 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 Starfield 01/09 SP 4118 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.
  • We know that Inappropriate referrals to specialists lead to greater frequency of tests and more false positive results than appropriate referrals to specialists. Inappropriate referrals to specialists lead to poorer outcomes than appropriate referrals. The socially advantaged have higher rates of visits to specialists than the socially disadvantaged. The more the training of MDs, the more the referrals. 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 A MAJOR ROLE OF PRIMARY CARE IS TO ASSURE THAT SPECIALTY CARE IS MORE APPROPRIATE AND, THEREFORE, MORE EFFECTIVE.
  • 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. Starfield 03/06 SP 3396 Sources: Forrest et al, BMJ 2002; 325:370-1. Valderas et al, Ann Fam Med 2008, in press.
  • Percentage of People Seeing at Least One Specialist in a Year Starfield 01/07 SP 3529 n 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. US 40% of total population; 54% of patients (users) Canada (Ontario) 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)
  • 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. Starfield 09/04 04-141 Source: Weingarten et al, Arch Intern Med 2002; 162:527-32. Starfield 09/04 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. Starfield 01/09 RC 4119 Source: Forrest & Reid, J Fam Pract 2001;50:427-32.
  • % 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 2000 00-078 How Frequently Do Specialists Take Care of People with “Specialty” Conditions? Starfield 10/00 SP 1744
  • Expected Resource Use (Relative to Adult Population Average) by Level of Co-Morbidity, British Columbia, 1997-98 Starfield 09/07 CM 3867 n Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005. Thus, it is co-morbidity, rather than presence or impact of chronic conditions, that generates resource use. None Low Medium High Very High Acute conditions only 0.1 0.4 1.2 3.3 9.5 Chronic condition 0.2 0.5 1.3 3.5 9.8 High impact chronic condition 0.2 0.5 1.3 3.6 9.9
  • 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. Starfield 01/09 D 4108 Sources: Mangione et al, Ann Intern Med 2006;145:107-16. Tsai et al, Am J Manag Care 2005;11:478-88
  • 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) Starfield 04/07 SP 3636 ALL of the above are also relevant for the type of specialist, and for the reason for visit.
  • 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* Starfield 01/07 SP 3524 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. *No evidence to date
  • 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. Starfield 01/07 SP 3549 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.
  • 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 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 Starfield 02/03 SP 2425
  • Questions Needing Answers 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? Can we clearly specify what it is that specialists can do that primary care physicians can’t do? Starfield 02/03 03-042 Starfield 02/03 SP 2426
  • Questions Needing Answers At what time during an episode of illness should one refer to a specialist? How can this appropriate time be measured? Is there evidence for a threshold of frequency such that something is too rare for primary care physicians to maintain competence? Is it good (or bad) that the rich see specialists more than the poor? Starfield 02/03 03-043 Starfield 02/03 SP 2427
  • Augmenting the Potential of Primary Care: Comprehensiveness Caring for all but uncommon conditions Starfield 08/02 02-140 Starfield 08/02 COMP 2166
  • Primary Care Orientation of Health Systems: Rating Criteria Practice Characteristics First-contact Longitudinality Comprehensiveness Coordination Family-centeredness Community orientation Starfield 11/02 02-406 sc Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 11/02 PC 2367 n
  • Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s Starfield 07/07 ICTC 3758 n 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
  • *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. System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s Starfield 03/05 ICTC 3099 n
  • Distribution of Reasons for Referral: Badalona, Spain Starfield 01/07 SP 3530 Notes: More than one reason is common. Although orthopedic referrals are the most common specialist referrals, the percentage of reasons for any one is low. Diabetes 24.4% (ophthalmology) Local inflammation/mass 16.5% (dermatology) 10.7% (general surgery) Molluscum contagiosum 13.0% (dermatology) Visual signs and symptoms 11.5% (ophthalmology) Lipoma 11.4% (general surgery) Benign/undefined skin neoplasia 10.8% (dermatology) Auditory signs and symptoms 10.5% (ENT)
  • Condition-specific Analysis of Referral Rate by Practice Prevalence for Selected Conditions with Adequate Sample Size (n=65) Source: Forrest & Reid, J Fam Pract 2001; 50:427-32. Starfield 01/09 RC 4124 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.
  • Average Number of Visits Per Year to Primary Care and Specialists by Morbidity Burden, Co-morbid Conditions, Managed Care Organizations, 1996 *p
  • Average Number of Visits Per Year to Primary Care and Specialists by Morbidity Burden, Co-morbid Conditions, Medicare *p
  • Co-morbidity and Volume of Visits to Primary Care Physicians Starfield 04/01 01-062 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 CMOS 1869
  • Co-morbidity and Visits to Specialists Starfield 09/03 03-147 For most common chronic conditions, non-elderly people with a lot of co-morbidity 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 CMOS 2530
  • 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 Starfield 04/01 CMOS 1870 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * l * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * This slide shows the four main policy characteristics related to effectiveness and equity of primary health care services: distribution of resources according to extent and type of health needs, progressivity of financing, degree of cost sharing, and breadth of services provided in primary care. Scores range from zero (0), where the policy characteristic is absent, to a score of 1, where the characteristic is present but poorly developed, to a score of 2, where the characteristic is well developed. Belgium, France, Germany, and the US have weak primary health care systems; Denmark, Finland, The Netherlands, Spain, and the UK have strong primary healthcare; and Australia, Canada, Japan, and Sweden are in-between. With few exceptions, countries with equity-focused health policy are countries with strong primary care; countries with weak policy characteristics have weak primary care health systems. Sources: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. van Doorslaer E, Wagstaff A, Rutten F. Equity in the Finance and Delivery of Health Care: An International Perspective. New York: Oxford University Press, 1993. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Sources: Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):201-218. Boerma WGW, van der Zee J, Fleming DM. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997; 47(421):481-486. Boerma WGW, Groenewegen PP, van der Zee J. General practice in urban and rural Europe: the range of curative services. Soc Sci Med 1998; 47:445-53. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * Source: 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 forthcoming. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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 ). 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * Sources: Rivo ML, Saultz JW, Wartman SA, DeWitt TG. Defining the generalist physician's training. JAMA 1994; 271(19):1499-1504. Boerma WG, van der ZJ, Fleming DM. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997; 47(421):481-486. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * Source: Bindman AB, Forrest CB, Britt H, Crampton P, Majeed A. Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys. BMJ 2007; 334(7606):1261-1266. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 new slides * * Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. This diagram contains all of the elements of health services systems, highlighting those that are important to the achievement of primary care. These essential functions of primary care require attention to the particular elements of capacity, to one special element of provider behavior, and two elements reflecting the activities of patients and populations. Although many other elements of capacity and performance are involved in primary care, the identified elements act as the essential enabler to achieve first contact care, person-focused care over time, comprehensiveness of care, and coordination of care.  Once these functions are achieved, ensuing behaviors are dealt with as elements of the quality of care that is provided when problems are recognized as needing attention. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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 (http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1). van Doorslaer E, Koolman X, Jones AM. Explaining income-related inequalities in doctor utilisation in Europe. Health Econ 2004; 13(7):629-647. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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 2008; in press. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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-Y, Lemke KW, Weiner JP. Ambulatory specialist use by non-hospitalized patients in US health plans: correlates and consequences. Submitted 2008. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians' specialty referral decisions. J Fam Pract 2001;50:427-32. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Spitzer M. Personal communication. ACG Users Conference, September 2000. 09 NZ comprehensiveness Feb * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * These data, from one province in Canada, show that there is little difference in resource use for people with only acute conditions, people with any chronic conditions, or people with only serious chronic conditions when the morbidity burden is the same. However, increasingly higher morbidity burden (i.e., more multi-morbidity) is associated with progressively higher resource use, and the increase is the same regardless of the type of diagnosis (acute, chronic, major chronic). Chronic conditions alone do not, by themselves, imply high need for resources. Source: Broemeling A-M, Watson D, Black C. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005. 09 NZ comprehensiveness Feb * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * 09 Vancouver guidelines Mar * * Sources: Mangione CM, Gerzoff RB, Williamson DF, et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006;145:107-16. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005;11:478-88. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Each country was also rated 0, 1, or 2 with regard to its achievement of the cardinal features of primary care practice. A score of 0 indicates poor achievement of the feature; a score of 1 indicates intermediate achievement, and a score of 2 indicates high achievement of the feature. First contact is the seeking of care for each newly occurring problem or need from a primary care practitioner rather than a specialist. Longitudinality is person-focused (not disease-focused) relationships over time with the primary care source. Comprehensiveness is the provision, by the primary care source, of services for all health-related needs except those too uncommon in the population for competence to be maintained. Coordination is the integration of care by the primary care source when services outside of primary are required. Two related characteristics were also rated. Family centeredness is the extent to which services are provided in a family context. Community orientation is the extent to which data on community health needs are taken into account in planning for primary care services. Source: Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York: Oxford University Press, 1998. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * During the 1990s, two successive international comparisons involved rating different countries on the strength of primary care within the country. Ratings of primary health care were obtained by rating 6 (and 9 in the later study) characteristics of policy in each country: efforts to distribute resources according to where they were most needed; maintaining low or no cost-sharing; financial access controlled or regulated by government; the type of primary care practitioner (family physician or a mixture of types including also general internists and general pediatricians); and the presence of patient lists by primary care practices. In the second study, the following were added: low or no copayments for primary care; strength of academic departments of family medicine; the presence of patient lists by primary care practices; and 24-hour availability of primary care practices. Extent of achievement of the clinical features of first contact care, person-focused care over time, comprehensiveness (breadth) of services, coordination of care, family centeredness, and community orientation were also rated. Each characteristic was rated on a scale of 0 to 2, then all scores were averaged to obtain a systems score, a practice score and a combined overall primary care score. Eleven, and then 13 industrialized countries were compared; this comparison led to three groups of countries: those with low scores, those with intermediate scores, and those with high scores. These three groupings were unchanged over the decade between the two studies. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * The primary care score has two parts: the first reflects the strength of primary health care (that is, policies oriented towards primary care), and the second reflects the practice of primary care at the clinical level. In this chart, the countries are ranked by each of their two sub-scores. The country with the best sub-score is ranked #1, and the one with the worst sub-score is ranked #13. The better the policies (systems rankings), the better the practices, indicating the importance of governmental policy to good practice. Based on data in Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002; 60(3):201-218. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * Source: Forrest CB, Reid RJ. Prevalence of health problems and primary care physicians' specialty referral decisions. J Fam Pract 2001; 50(5):427-432. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * 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 co-morbidity (diagnoses additional to any specified main diagnosis), it is the visits for co-morbid 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * * * For the elderly in the United States, the additional visits to specialists in a year resulting from co-morbid 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. 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * * 09 NZ comprehensiveness Feb * *
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