Upload
trevet
View
775
Download
4
Embed Size (px)
DESCRIPTION
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
Citation preview
Comprehensiveness of Care: Concept and
Importance
Barbara Starfield, MD
Presented at:RNZCGP Annual Quality Symposium
Wellington, NZFebruary 14, 2009
“Basic Coverage” versus Comprehensive Primary Care
Starfield 01/09COMP 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 01/07COMP 3536
Comprehensiveness is the feature of primary care practice that is most salient in distinguishing primary care-oriented countries from other countries.
Starfield 01/07COMP 3571
System Features Important to Primary Health Care
Starfield 11/06EQ 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
BelgiumFranceGermanyUS
0000
0010
0020
0000
AustraliaCanadaJapanSweden
1112
2222
2211
2211
DenmarkFinlandNetherlandsSpainUK
22222
22022
21222
22212
**
Criteria for Comprehensiveness
Starfield 10/07COMP 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 05/06SP 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 04/07SP 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 09/07CMOS 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 09/0404-145
(Data controlled for sociodemographic characteristics, co-morbidity, and severity of illness)
SP 2964
Starfield 09/04SP 2964
Royal College of Physicians and SurgeonsTask Force to Review Fundamental Issues in
Specialty Education
Starfield 01/09SP 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 09/08COMP 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 01/07COMP 3538Sources: Rivo et al, JAMA 1994; 271:1499-1504. Boerma et al, Br J Gen Pract 1997; 47:481-6.
Comprehensiveness in Primary Care
Wart removal IUD insertionIUD removalPap smear
Suturing lacerations Tympanocentesis
Removal of cysts Vision screening
Joint aspiration/injectionForeign body removal (ear, nose)Setting of simple fracturesSprained ankle splint
Age-appropriate surveillanceFamily planningImmunizationsSmoking counseling
Remove ingrowing toenail Hearing screening
Behavior/MH counseling Home visits as needed
Electrocardiography Nutrition counseling
Examination for dental status OTHERS?
Starfield 03/08COMP 4008
In New Zealand, Australia, and the US, an average of 1.4 problems (excluding visits for prevention) were managed in each visit. However, primary care physicians in the US managed a narrower range: 46 problems accounted for 75% of problems managed in primary care, as compared with 52 in Australia and 57 in New Zealand.
Starfield 01/07COMP 3537Source: 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 04/0404-047Starfield 04/04COMP 2817
Primary Care Oriented Health Services
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 04/08HS 4139 n
CAPACITY
PERFORMANCE
HEALTH STATUS(outcome)
Provisionof care
Receiptof care
PersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsKnowledge baseAccessibilityFinancingPopulation eligibleGovernance
Person-focused relationship
Cultural andbehavioral
characteristics
Social, political,economic, and
physical environments
Biologic endowmentand prior health
Problem recognitionDiagnosisManagementReassessment
UtilizationAcceptance and satisfactionUnderstandingParticipation
LongevityComfortPerceived well-beingDiseaseAchievementRisksResilience
Community resources
The Health Services System: Comprehensiveness
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 199999-014
CAPACITY
PERFORMANCE
HEALTH STATUS(outcome)
Provisionof
care
Receipt ofcare
Range of services
Problem recognition
Starfield 1999HS 1441
PCAT: Comprehensiveness Subdomains
Services available
Services provided (received)
Starfield 01/0202-022Starfield 01/02PCM 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 199696-24
Starfield 05/96PCM 1017
PCAT: Comprehensiveness(Services Available*)
Following is a list of services that you or your family might need at some time. For each one, please indicate whether it is available at your PCP’s office.
1. Family planning or birth control methods
2. Counseling for mental health problems
3. Sewing up a cut that needs stitches
4. Vision screening
Starfield 01/0202-027Starfield 01/02PCM 2052
*Examples
PCAT: Comprehensiveness(Services Provided*)
In visits to your PCP, are any of the following things discussed with you?
1. Advice about healthy foods and unhealthy foods
2. Ways to handle family conflicts that may arise from time to time
3. Advice about appropriate exercise for you
4. Checking on and discussing the medications you are taking
Starfield 01/0202-028Starfield 01/02PCM 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 01/09SP 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 that1. Inappropriate referrals to specialists lead to
greater frequency of tests and more false positive results than appropriate referrals to specialists.
2. Inappropriate referrals to specialists lead to poorer outcomes than appropriate referrals.
3. The socially advantaged have higher rates of visits to specialists than the socially disadvantaged.
4. The more the training of MDs, the more the referrals.
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 08/05SP 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 03/06SP 3396Sources: 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 01/07SP 3529 n
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)
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.
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 09/0404-141Source: Weingarten et al, Arch Intern Med 2002; 162:527-32. Starfield 09/04SP 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 01/09RC 4119Source: 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 200000-078
How Frequently Do Specialists Take Care of People with “Specialty” Conditions?
Starfield 10/00SP 1744
Expected Resource Use (Relative to Adult Population Average) by Level of Co-Morbidity, British Columbia, 1997-98
Starfield 09/07CM 3867 n
None Low Medium HighVery 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
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.
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 01/09D 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 02/09COMP 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 04/07SP 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 01/07SP 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 01/07SP 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 01/07SP 3533
Questions Needing Answers
1. Is the greater use of diagnostic technology among specialists only because of higher prior probability of a positive result, or is there some inherent predisposition to using diagnostic tests among specialty-oriented physicians?
Starfield 02/0303-041Starfield 02/03SP 2425
Questions Needing Answers
2. Is co-morbidity associated with more hospitalizations for ambulatory care sensitive conditions (ACSC) because there is simply more pathology or because medical care does a poor job of detecting and treating co-morbidity?
3. Can we clearly specify what it is that specialists can do that primary care physicians can’t do?
Starfield 02/0303-042Starfield 02/03SP 2426
Questions Needing Answers
4. At what time during an episode of illness should one refer to a specialist? How can this appropriate time be measured?
5. Is there evidence for a threshold of frequency such that something is too rare for primary care physicians to maintain competence?
6. Is it good (or bad) that the rich see specialists more than the poor?
Starfield 02/0303-043Starfield 02/03SP 2427
Augmenting the Potentialof Primary Care:
Comprehensiveness
• Caring for all but uncommon conditions
Starfield 08/0202-140Starfield 08/02COMP 2166
Primary Care Orientation of Health Systems: Rating Criteria
• Practice Characteristics– First-contact
– Longitudinality
– Comprehensiveness
– Coordination
– Family-centeredness
– Community orientation
Starfield 11/0202-406 sc
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 11/02PC 2367 n
Primary Care Scores, 1980s and 1990s
1980s 1990s
BelgiumFrance*
GermanyUnited States
0.8-
0.50.2
0.40.30.40.4
AustraliaCanadaJapan*
Sweden
1.11.2
-1.2
1.11.20.80.9
DenmarkFinland
NetherlandsSpain*
United Kingdom
1.51.51.5
-1.7
1.71.51.51.41.9
*Scores available only for the 1990s Starfield 07/07ICTC 3758 n
0123456789
101112
0 1 2 3 4 5 6 7 8 9 10 11 12 13
System Characteristics (Rank*)
Pra
ctic
e C
ha
ract
eri
stic
s (R
an
k*)
UK
NTH
SP
FIN CANAUS
SWE JAP
GER FRBEL
US
DK
*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 03/05ICTC 3099 n
Distribution of Reasons for Referral: Badalona, Spain
Starfield 01/07SP 3530
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)
Notes:1. More than one reason is common.2. Although orthopedic referrals are the most common specialist
referrals, the percentage of reasons for any one is low.
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 01/09RC 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<.0001
1.69
3.46
5.68
0.68
1.81
4.32
0
1
2
3
4
5
6
7
8
9
Low-medium High Very high
Morbidity Group
Mea
n N
um
ber
of
Vis
its
Primary Care Physician Specialist
*
*
*
Based on data in Starfield et al, Ann Fam Med 2003; 1:8-14.Starfield 08/08SP 4054 n
Average Number of Visits Per Year to Primary Care and Specialists by Morbidity Burden,
Co-morbid Conditions, Medicare
*p<.0001
2.12
3.9
6.57
1.8
4.32
8.95
0
1
2
3
4
5
6
7
8
9
Low-medium High Very high
Morbidity Group
Me
an
Nu
mb
er
of
Vis
its
Primary Care Physician Specialist
*
*
*
Source: Starfield et al, Ann Fam Med 2005; 3:215-22. Starfield 08/08SP 4055 n
Co-morbidity and Volume of Visits to Primary Care Physicians
Starfield 04/0101-062
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 04/01CMOS 1869
Co-morbidity and Visits to Specialists
Starfield 09/0303-147
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 09/03CMOS 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 04/0101-063Starfield 04/01CMOS 1870