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Wonca 2004
By every accepted epidemiological measure -- birth weight, infant mortality, life expectancy, to name a few -- primary care-oriented health systems are associated with healthier populations that live longer. That's the contention of Barbara Starfield, M.D., M.P.H., professor of health policy and management at the Johns Hopkins University Bloomberg School of Public Health, Baltimore.
Starfield, who was introduced as the "grand lady of public health," addressed worldwide issues in primary care in an Oct. 13 session.
Citing international studies, Starfield said increasing the number of primary care physicians is positively associated with improved health outcomes, while increasing the number of specialty physicians appears to have the opposite effect.
For example, in the United States, a "20 percent increase in the number of primary care physicians is associated with a 5 percent decrease in mortality (40 fewer deaths per 100,000)," she said. But the benefit is even greater if the primary care physician is a family physician. Adding one more FP per 10,000 people "is associated with 70 fewer deaths per 100,000, which is a 9 percent reduction in mortality," she said.
Moreover, she said that when specialists practice outside their area of specialization, the result is an increase in mortality rates for "acquired pneumonia, acute myocardial infarction, congestive heart failure and upper GI hemorrhage." Noting that specialists are "trained to look for zebras instead of horses," she said specialty care usually means more "tests, which lead to a cascade effect and consequently greater likelihood of adverse effects, including death."
The reality of medical practice, Starfield said, is that while "specialists may, and in fact do, follow guidelines better than primary care physicians, specialists cannot deal with comorbidities. And guidelines don't account for comorbidities." This observation triggered a burst of applause from the audience at the 17th World Conference of Family Doctors.
Primary care, Starfield said, "is more effective, efficient and more equitable" than specialty care. For example, a 1994 study of the major determinants of health outcomes in all 50 U.S. states found that when the number of "specialty physicians increased, all outcomes were worse." Likewise, worse outcomes were directly related to a decline in the supply of primary care physicians.
During the discussion period, Starfield was asked why her data have failed to move Congress to increase funding for primary care. "If you are asking what is in the heads of congressmen, I think you know," she said. They are thinking: ‘What will this mean for big pharma? What will this mean for the medical device companies? What will this mean for insurance companies?' Those are the powerful forces in Congress. If primary care is to grow, it needs to find powerful allies in the population, which is difficult because the population is brainwashed to believe the best care comes from specialists. The only ally of primary care is business because business pays the bills."
Finally, Starfield challenged Wonca to support research in three key areas: the impact of comorbidity on the development of clinical and preventive care guidelines; new strategies to develop a better relationship between primary care and specialty physicians; and cross-country and cross-area variations in referral rates to serve as a basis for a better definition of the roles of primary care and specialty physicians.
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Copyright © 2004 by American Academy of Family Physicians.