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Primary Care/Specialty Care in the Era of Multimorbidity  Barbara Starfield, MD, MPH   19th WONCA World Conference of     ...
United States $7,290                                                                                                   The...
Country* Clusters: Health Professional      Supply and Child Survival                                         25          ...
Primary Care and Specialist Physicians per 1000         Population, Selected OECD Countries, 2007                         ...
Why Is Primary Care    Important?Better health outcomesLower costsGreater equity in health                           Starf...
Primary health care oriented countries       • Have more equitable resource distributions       • Have health insurance or...
Primary Care Strength and Premature                 Mortality in 18 OECD Countries    10000PYLL                           ...
Many other studies done WITHIN countries,     both industrialized and developing, show that     areas with better primary ...
Strategy for Change in Health Systems  •   Achieving primary care  •   Avoiding an excess supply of specialists  •   Achie...
Primary Care Scores by Data Source, PSF Clinics                                                         Access            ...
A study of individuals seen in a year in large health     care plans in the US found:                                     ...
A study of individuals (ages 20-79) seen         over two years in Ontario, Canada, found:             percent who saw a s...
The US has a significantly higher     proportion of people (compared with     Canada, France, Netherlands, New     Zealand...
Percent of Patients Reporting Any        Error by Number of Doctors Seen                in Past Two Years          Country...
In the United States, half of all     outpatient visits to specialist physicians     are for the purpose of routine follow...
In New Zealand, Australia, and the US,     an average of 1.4 problems (excluding     visits for prevention) were managed i...
Comprehensiveness in primarycare is necessary in order toavoid unnecessary referrals tospecialists, especially in peoplewi...
30% of PCPs and 50% of specialists in     southwestern Ontario reported that scope     of primary care practice has increa...
The Declining Comprehensiveness of                          Primary Care                                                  ...
Comprehensiveness in Primary Care*               Wart removal                                          IUD insertion      ...
Comprehensiveness: Canadian Family                        Physicians     Advanced procedural skills                       ...
Provincial Participation Rates of Canadian Fee-for-            Service Family Physicians in: Advanced and Basic           ...
The Appropriate Management of Multimorbidity in Primary            Care                           Starfield 04/10         ...
Percentage of Patients Referred in a Year: US vs. UK            90            80                                          ...
Top 5 Predictors of Referrals, US    Collaborative Practice Network, 1997-99             All referrals                    ...
The more common the condition in primary care      visits, the less the likelihood of referral, even after      controllin...
Percent Distribution by Degree of Comorbidity for     Selected Disease Groups, Non-elderly Population                     ...
Comorbidity Prevalence    1. The percentage of Medicare beneficiaries with 5+       treated conditions increased from 31 t...
Differences in Mean Number of Chronic     Conditions among Enrollees Age 65+ Reporting      Congestive Heart Failure, by R...
Comorbidity, Inpatient Hospitalization,                                  Avoidable Events, and Costs*                     ...
Controlled for morbidity burden*:      The more DIFFERENT generalists seen: higher      total costs, medical costs, diagno...
Resource Use, Controlling for          Morbidity Burden*       The more DIFFERENT specialists       seen, the higher total...
Summary of Predictability of Year 1 Characteristics,     with Regard to Subsequent Year’s (3 or 5) Costs                  ...
Influences* on Use of Family Physicians and          Specialists, Ontario, Canada, 2000-1                                 ...
Expected Resource Use (Relative to Adult            Population Average) by Level of         Comorbidity, British Columbia,...
Results: Case-mix by SES - ACG                         0.66                         0.64       Mean ACG weight            ...
Results: Capitation Fee and                                                       Morbidity by SES                        ...
Methods (I)     • Representative sample of 66,500 adults       (age 18 or older) enrolled in Clalit Health       Services ...
Methods (II)     • Morbidity spectrum: ADGs were used to classify       the population into 3 groups:            – Low (0-...
Methods (III)     Resource use:            – Costs: total, hospital, ambulatory              (standardized price X unit)  ...
Resource Use in Adults with No           Chronic Condition     14% of persons with no chronic conditions have an     avera...
Resource Use by Spectrum of Morbidity: Adults            with No Chronic Conditions (N=28,700)Source: Shadmi et al, Morbid...
Resource Use in Adults with                      Chronic Conditions     • Some people with as many as 6 chronic conditions...
Resource Use by Spectrum of Morbidity: Persons            with 3 Chronic Conditions (N=4,900)Source: Shadmi et al, Morbidi...
Morbidity Spectrum Explains        Health Care Resource Use (R2)                                                          ...
Chronic Conditions and Use of Resources     Implications for care management:        – Care management based on selection ...
Applications of Morbidity-Mix Adjustment1.    Physician/group oriented       • Characterizing and explaining variability i...
Choice of Comorbidity Measure      Depends on the Purpose•   population morbidity assessments•   prediction of death•   pr...
Multimorbidity and Use of Primary  and Secondary Care Services• Morbidity and comorbidity (and hence  multimorbidity) are ...
We know that           1. Inappropriate referrals to specialists lead to              greater frequency of tests and more ...
What is the right number of        specialists?   What do specialists do?What do specialists contribute   to population he...
What We Do Not KnowThe contribution of specialists to• Unnecessary care (due to overestimation  of the likelihood of disea...
What We Need to Know• What specialists contribute to population  health• The optimum ratio of specialists to population• T...
Aspects of Care That Distinguish            Conventional Health Care from People-                    Centred Primary CareS...
ConclusionVirchow said that medicine is a socialscience and politics is medicine on a grandscale.Along with improved socia...
ConclusionAlthough sociodemographic factorsundoubtedly influence health, a primarycare oriented health system is a highlyr...
Strategy for Change in Health Systems  •   Achieving primary care  •   Avoiding an excess supply of specialists  •   Achie...
Percentage of Visits in Which          Patients Were Referred: US                                       1994   2006       ...
Family Physicians, General          Internists, and Pediatricians      A nationally representative study showed that adult...
Having a general internist as the PCP     is associated with more different     specialists seen. Controlling for     diff...
The greater the morbidity burden,the greater the persistence of anygiven diagnosis.That is, with high comorbidity,even acu...
Results: Case-mix of Age                    Groups – Females                                                             S...
Results: Case-mix of Age                     Groups – Males                                                             St...
Results: Income Quintiles                      25                      20        % of sample                      15      ...
Results: Capitation Fee by SES                                    1.15                                    1.14        Mean...
Results: Case-mix by SES - ADG                         2.95                         2.90       Mean ADG counts            ...
Barbara starfield presentation cancun wonca may 05 27-10
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Presentacion de Barbra Starfield en Congreso WONCA - CIMF , Cancun 2010.

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  1. 1. Primary Care/Specialty Care in the Era of Multimorbidity Barbara Starfield, MD, MPH 19th WONCA World Conference of Family Doctors Cancun, Mexico May 19-23, 2010
  2. 2. United States $7,290 The Cost of Care Dollar figures reflect all public and private spending on care, from doctor visits to hospital infrastructure. Data are from 2007 or the most recent year available.Source: http://blogs.ngm.com/.a/6a00e0098226918833012876674340970c-800wi (accessed January Starfield 01/104, 2010). Graphic by Oliver Liberti, National Geographic staff. Data from OECD Health Data 2009. IC 7251 n
  3. 3. Country* Clusters: Health Professional Supply and Child Survival 25 15 10 Density (workers per 1000) 5.0 2.5 1 3 5 9 50 100 250 Child mortality (under 5) per 1000 live births*186 countries Starfield 07/07Source: Chen et al, Lancet 2004; 364:1984-90. HS 6333 n
  4. 4. Primary Care and Specialist Physicians per 1000 Population, Selected OECD Countries, 2007 Country Primary Care Specialists Belgium 2.2 2.2 France 1.6 1.7 Germany 1.5 2.0 US 1.0 1.5 Australia 1.4 1.4 Canada 1.0 1.1 Sweden 0.6 2.6 Denmark 0.8 1.2 Finland 0.7 1.6 Netherlands 0.5 1.0 Spain 0.9 1.2 UK 0.7 1.8 Norway 0.8 2.2 Switzerland 0.5 2.8 New Zealand 0.8 0.8 OECD average 0.9 1.8 Starfield 03/10Source: OECD Health Data 2009 WF 7318 n
  5. 5. Why Is Primary Care Important?Better health outcomesLower costsGreater equity in health Starfield 07/07 PC 6306 n
  6. 6. Primary health care oriented countries • Have more equitable resource distributions • Have health insurance or services that are provided by the government • Have little or no private health insurance • Have no or low co-payments for health services • Are rated as better by their populations • Have primary care that includes a wider range of services and is family oriented • Have better health at lower costsSources: Starfield and Shi, Health Policy 2002; 60:201-18.van Doorslaer et al, Health Econ 2004; 13:629-47. Starfield 11/05Schoen et al, Health Aff 2005; W5: 509-25. IC 6311
  7. 7. Primary Care Strength and Premature Mortality in 18 OECD Countries 10000PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 1990 2000 Year*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlledfor GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R 2(within)=0.77. Starfield 11/06Source: Macinko et al, Health Serv Res 2003; 38:831-65. IC 5903 n
  8. 8. Many other studies done WITHIN countries, both industrialized and developing, show that areas with better primary care have better health outcomes, including total mortality rates, heart disease mortality rates, and infant mortality, and earlier detection of cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma. The opposite is the case for higher specialist supply, which is associated with worse outcomes.Sources: Starfield et al, Milbank Q 2005;83:457-502. Starfield 09/04Macinko et al, J Ambul Care Manage 2009;32:150-71. WC 6314
  9. 9. Strategy for Change in Health Systems • Achieving primary care • Avoiding an excess supply of specialists • Achieving equity in health • Addressing co- and multimorbidity • Responding to patients’ problems: using ICPC for documenting and follow-up • Coordinating care • Avoiding adverse effects • Adapting payment mechanisms • Developing information systems that serve care functions as well as clinical information • Primary care-public health link: role of primary care in disease prevention Starfield 11/06 HS 6457 n
  10. 10. Primary Care Scores by Data Source, PSF Clinics Access 5 Total Score 4 Longitudinal 3 2 Resources 1 Providers First Contact Gatekeeping Available 0 Community Comprehensive Family focus Coordination PSF (users) PSF (providers) PSF (managers)Source: Almeida & Macinko. [Validation of a Rapid Appraisal Methodology forMonitoring and Evaluating the Organization and Performance of Primary Health Care Starfield 05/06Systems at the Local Level]. Brasília: Pan American Health Organization, 2006. WC 6592 n
  11. 11. A study of individuals seen in a year in large health care plans in the US found: elderly non-elderly percent who saw a 95 69 specialist average number of 4.0 1.7 different specialists seen average number of visits 8.8 3.3 to specialists total visits to both 11.5 5.9 primary care and specialists Starfield 02/10Source: Starfield et al, J Ambul Care Manage 2009;32:216-25. COMP 7284 n
  12. 12. A study of individuals (ages 20-79) seen over two years in Ontario, Canada, found: percent who saw a specialist 53.2 median number of visits to 1.0 specialists total visits to both primary 7.0 care and specialists Starfield 02/10Source: Sibley et al, Med Care 2010;48:175-82. COMP 7322 n
  13. 13. The US has a significantly higher proportion of people (compared with Canada, France, Netherlands, New Zealand, United Kingdom) who see two or more specialists in a year – 27%, and 38% among people with chronic illness. Even these figures, obtained from population surveys, understate the heavy use of multiple physicians seen in a year in the US.Sources: Schoen et al, Health Aff 2007;26:W717-34. Starfield 02/10Schoen et al, Health Aff 2009;28:w1-16. COMP 7283
  14. 14. Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Country One doctor 4 or more doctors Australia 12 37 Canada 15 40 Germany 14 31 New Zealand 14 35 UK 12 28 US 22 49 Starfield 09/07Source: Schoen et al, Health Affairs 2005; W5: 509-525. IC 6525 n
  15. 15. In the United States, half of all outpatient visits to specialist physicians are for the purpose of routine follow-up. Does this seem like a prudent use of expensive resources, when primary care physicians could and should be responsible for ongoing patient-focused care over time? Starfield 08/09Source: Valderas et al, Ann Fam Med 2009;7:104-11. SP 6528
  16. 16. 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 01/07Source: Bindman et al, BMJ 2007; 334:1261-6. COMP 6659 n
  17. 17. Comprehensiveness in primarycare is necessary in order toavoid unnecessary referrals tospecialists, especially in peoplewith comorbidity. Starfield 02/09 COMP 7090
  18. 18. 30% of PCPs and 50% of specialists in southwestern Ontario reported that scope of primary care practice has increased in the past two years. Physicians in solo practice or hospital-based were more likely to report an increase than those in large groups. Family physicians were less likely than general internists or pediatricians to express concern about increasing scope.Source: St. Peter et al, The Scope of Care Expected of Primary CarePhysicians: Is It Greater Than It Should Be? Issue Brief 24. Center for Studying Starfield 04/10Health System Change (http://www.hschange.com/CONTENT/58/58.pdf), 1999. COMP 7332
  19. 19. The Declining Comprehensiveness of Primary Care Starfield 03/10Source: Chan BT. The declining comprehensiveness of primary care. CMAJ 2002;166:429-34. COMP 7330
  20. 20. Comprehensiveness in Primary Care* Wart removal IUD insertion IUD removal Pap smear Suturing lacerations Hearing screening Removal of cysts Vision screening Joint aspiration/injection Age-appropriate surveillance Foreign body removal (ear, nose) Family planning Sprained ankle splint Immunizations Smoking counseling Remove ingrowing toenail Home visits as needed Behavior/MH counseling Nutrition counseling Electrocardiography OTHERS? Examination for dental status Starfield 03/08*Unanimous agreement in a survey of family physician experts in ten countries (2008) COMP 6959 n
  21. 21. Comprehensiveness: Canadian Family Physicians Advanced procedural skills Basic procedural skills • Sigmoidoscopy • Insertion of IUD • Intensive care/resuscitation • Biopsy • Nerve blocks • Cryotherapy • Minor fractures • Electrocardiogram • Chalazion • Injection/aspiration of joint • Tumour excision • Allerlgy/hyposensitization test • Vasectomy • Excision of nail • Varicose veins • Wound suture • Rhinoplasty • Removal of foreign body • Fractures • Incision, abscess, etc. NOTE that British Columbia family physicians are more comprehensive than their counterparts in other provinces.Source: Canadian Institute for Health Information. TheEvolving Role of Canadas Fee-for-Service Family Starfield 02/09Physicians, 1994-2003: Provincial Profiles. 2006. COMP 7095 n
  22. 22. Provincial Participation Rates of Canadian Fee-for- Service Family Physicians in: Advanced and Basic Procedural SkillsSource: National Physician Database, CIHI, as summarized in CanadianInstitute for Health Information, The Evolving Role of Canadas Fee-for- Starfield 02/09Service Family Physicians, 1994-2003: Provincial Profiles, 2006. COMP 7093 n
  23. 23. The Appropriate Management of Multimorbidity in Primary Care Starfield 04/10 CM 7334
  24. 24. Percentage of Patients Referred in a Year: US vs. UK 90 80 US Health Plans 70 60 50 UK 40 30 20 10 0 0.0 0.0 0.0 0.5 0.5 1.0 1.0 1.5 1.5 2.0 2.0 2.5 2.5 Healthier Treated Morbidity Index Score Sicker (ACGs) Starfield 04/08Source: Forrest et al, BMJ 2002; 325:370-1. CM 5871 n
  25. 25. Top 5 Predictors of Referrals, US Collaborative Practice Network, 1997-99 All referrals Discretionary referrals† High comorbidity burden Patient ages 0-17* Uncommon primary diagnosis Nurse referrals permitted Moderate morbidity burden Northeast region Surgical diagnoses Physician is an internist. Gatekeeping Gatekeeping with capitation** NOTE: * No pediatricians included in study ** Specialists not in capitation plan †Common conditions + high certainty for diagnosis and treatment + low cogency + only cognitive assistance requested. Constituted 17% of referrals. Starfield 10/05Source: Forrest et al, Med Decis Making 2006;26:76-85. RC 6497
  26. 26. 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 comorbidity is very high, referral is more likely, even in the presence of common problems. IS THIS APPROPRIATE? IS SEEING A MULTIPLICITY OF SPECIALISTS THE APPROPRIATE STRATEGY FOR PEOPLE WITH HIGH COMORBIDITY? Starfield 03/10Source: Forrest & Reid, J Fam Pract 2001;50:427-32. RC 7068
  27. 27. Percent Distribution by Degree of Comorbidity for Selected Disease Groups, Non-elderly Population Morbidity Burden Level (ACGs) Disease Group Low Mid High Total population 69.0* 27.5 4.0 Asthma 24.0 63.8 12.2 Hypertension 20.7 65.4 13.9 Ischemic heart disease 3.9 49.0 47.1 Congestive heart failure 2.6 35.1 62.3 Disorders of lipoid metabolism 17.6 69.9 12.5 Diabetes mellitus 13.9 63.2 22.9 Osteoporosis 11.1 50.0 38.9 Thrombophlebitis 12.2 53.8 33.9 Depression, anxiety, neuroses 8.1 66.3 25.6 Starfield 12/04*About 20% have no comorbidity. Source: ACG Manual CM 5690 n
  28. 28. Comorbidity Prevalence 1. The percentage of Medicare beneficiaries with 5+ treated conditions increased from 31 to 40 to 50 in 1987, 1997, 2002. 2. The age-adjusted prevalence increased for • Hyperlipidemia: 2.6 to 10.7 to 22.2 • Osteoporosis: 2.2 to 5.2 to 10.3 • Mental disorders: 7.9 to 13.1 to 19.0 • Heart disease: 27.0 to 26.1 to 27.8 3. The percentage of those with 5+ treated conditions who reported being in excellent or good health increased from 10% to 30% between 1987 and 2002. MESSAGE: “Discretionary diagnoses” are increasing in prevalence, particularly those associated with new pharmaceuticals. How much of this is appropriate? Starfield 08/06Source: Thorpe & Howard, Health Aff 2006; 25:W378-W388. CM 6600
  29. 29. Differences in Mean Number of Chronic Conditions among Enrollees Age 65+ Reporting Congestive Heart Failure, by Race/Ethnicity, Income, and Education: 1998 5.6 5.48 5.5 5.44 5.4 5.31 5.29 5.3 Mean 5.2 5.1 5.01 5.0 4.9 4.8 4.7 All Non-Hispanic Hispanic or Less than a Poor: Less than Black or African Spanish High School $10,000 Income American Education Starfield 11/06Source: Bierman, Health Care Financ Rev 2004; 25:105-17. CM 6337 n
  30. 30. Comorbidity, Inpatient Hospitalization, Avoidable Events, and Costs* 400 16000 362 13,973 (4 or more 350 conditions) 14000 296 300 12000 267 Rate per 1000 beneficiaries 250 10000 216 233 Costs 200 8000 169 182 150 6000 152 4701 119 119 100 4000 74 2394 86 50 40 2000 57 1154 20 34 211 8 17 0 1 4 8 0 0 1 2 3 4 5 6 7 8 9 10+ Number of types of conditions ACSC Complications CostsSource: Wolff et al, Arch Starfield 11/06Intern Med 2002; 162:2269-76. *ages 65+, chronic conditions only CM 5686 n
  31. 31. Controlled for morbidity burden*: The more DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventions. The more different generalists seen, the 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.*Using the Johns Hopkins Adjusted Clinical Groups (ACGs) Starfield 02/10Source: Starfield et al, J Ambul Care Manage 2009;32:216-25. LONG 7288
  32. 32. Resource Use, Controlling for Morbidity Burden* The more DIFFERENT specialists seen, the higher total costs, medical costs, diagnostic tests and interventions, and types of medication.*Using the Johns Hopkins Adjusted Clinical Groups (ACGs) Starfield 04/10Source: Starfield et al, J Ambul Care Manage 2009;32:216-25. SP 7333
  33. 33. Summary of Predictability of Year 1 Characteristics, with Regard to Subsequent Year’s (3 or 5) Costs Rank for Under- Over- relative risk predictive* predictive 1+ hospitalizations 5 90% 40% 8+ morbidity types (ADGs) 2 64% 55% 4+ major morbidity types (ADGs) 1 75% 30% Top 10th percentile for costs 4 96% 70% (ACGs) 10+ specific diagnoses 3 82% 40%*Underpredictive:% of those with subsequent high cost who did not havethe characteristicOverpredictive: % with characteristic who are not subsequently high cost Starfield 09/00 CM 5577 n
  34. 34. Influences* on Use of Family Physicians and Specialists, Ontario, Canada, 2000-1 Primary care visits Specialty visits One or One or Type of influence Mean Median more Mean Median more # different types of 1 1 1 1 1 1 morbidity (ADGs) Morbidity burden 2 2 2 2 2 2 (ACGs) Self-rated health 3 3 5 3 - 5 Disability 4 4 4 4 4 4 # chronic conditions** 5 5 3 - - - Age 65 or more - - - 5 3 3 *top five, in order of importance **from a list of 24, including “other longstanding conditions” Starfield 02/10Calculated from Table 2 in Sibley et al, Med Care 2010;48:175-82. CM 7317
  35. 35. Expected Resource Use (Relative to Adult Population Average) by Level of Comorbidity, British Columbia, 1997-98 Very None Low Medium High High Acute conditions 0.1 0.4 1.2 3.3 9.5 only Chronic condition 0.2 0.5 1.3 3.5 9.8 High impact chronic 0.2 0.5 1.3 3.6 9.9 condition Thus, it is comorbidity, rather than presence or impact of chronic conditions, that generates resource use.Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents Starfield 09/07of British Columbia. Vancouver, BC: University of British Columbia, 2005. CM 6622 n
  36. 36. Results: Case-mix by SES - ACG 0.66 0.64 Mean ACG weight 0.62 0.60 0.58 0.56 0.54 0.52 0.50 Q1 (Lowest) Q2 Q3 Q4 Q5 (Highest) SES quintiles Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7327 n
  37. 37. Results: Capitation Fee and Morbidity by SES 1.10 Standardized Morbidity and Fee Index Age-Sex Capitation Fee ACG Weight 1.05 1.00 0.95 0.90 Q1 (Lowest) Q2 Q3 Q4 Q5 (Highest) Income Quintile Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7329 n
  38. 38. Methods (I) • Representative sample of 66,500 adults (age 18 or older) enrolled in Clalit Health Services (Israel’s largest health plan) during 2006 • Data from diagnoses registered in electronic medical records during all encounters (primary, specialty, and hospital), and health care use registered in Clalit’s administrative data warehouseSource: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7335
  39. 39. Methods (II) • Morbidity spectrum: ADGs were used to classify the population into 3 groups: – Low (0-2 ADGs) – Medium (3-5 ADGs) – High (>=6 ADGs) • Clalit’s Chronic Disease Registry (CCDR): – ~180 diseases. Based on data from diagnoses, lab tests, Rx • Charlson Index: – Based on data from the CCDR – Range 0-19Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7336
  40. 40. Methods (III) Resource use: – Costs: total, hospital, ambulatory (standardized price X unit) – Specialist visits – Primary care physician visits – Resource use ratio: mean total cost per morbidity group divided by the average total costSource: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7337
  41. 41. Resource Use in Adults with No Chronic Condition 14% of persons with no chronic conditions have an average resource use ratio higher than that of some of the people with 5 or more chronic conditions. That is, resource use in populations is not highly related to having a chronic condition, in the absence of consideration of other conditions.Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7338
  42. 42. Resource Use by Spectrum of Morbidity: Adults with No Chronic Conditions (N=28,700)Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7339
  43. 43. Resource Use in Adults with Chronic Conditions • Some people with as many as 6 chronic conditions have less than average resource use • Prevalent conditions in persons with 6 chronic diseases and below average resource use: – 60% hyperlipidemia – 32% diabetes – 27% obesity – 10% hypertension – 10% depression That is, resource use is more highly related to the types of co-morbidity than to specific chronic conditions.Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7340
  44. 44. Resource Use by Spectrum of Morbidity: Persons with 3 Chronic Conditions (N=4,900)Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7341
  45. 45. Morbidity Spectrum Explains Health Care Resource Use (R2) Total Hospital cost* costs* Age, sex 12% 6% Chronic condition count, 20% 9% age, sex Charlson, age, sex 22% 12% ADG, age sex 42% 27% *Total costs: Hospital, ambulatory and Rx costs trimmed at 3 standard deviations above the mean.Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7342
  46. 46. Chronic Conditions and Use of Resources Implications for care management: – Care management based on selection of patients based on chronic disease counts (e.g., persons with 4 or more chronic conditions) will include many “false positives” (i.e., persons with low morbidity burden and low associated resource use) and will miss many who could benefit from such interventions. • Implications for research: – Adjustment for morbidity based on chronic condition counts or the Charlson score fails to capture the morbidity burden of 40-60% of the population. – Adjustments using chronic condition counts or the Charlson score explain only half or less of the variance explained by ADGs (morbidity spectrum).Source: Shadmi et al, Morbidity pattern and resource use Starfield 04/10in adults with multiple chronic conditions, presented 2010. CMOS 7343
  47. 47. Applications of Morbidity-Mix Adjustment1. Physician/group oriented • Characterizing and explaining variability in resource use • Understanding the use of and referrals to specialty care • Controlling for comorbidity • Capitation payments • Refining payment for performance2. Patient/population oriented • Identifying need for tailored management in population subgroups • Surveillance for changes in morbidity patterns • Targeting disparities reduction Starfield 03/06 CM 6545
  48. 48. Choice of Comorbidity Measure Depends on the Purpose• population morbidity assessments• prediction of death• prediction of costs• prediction of need for primary care services• prediction of use of specialty servicesThe US is focused heavily on costs of care. Therefore, itfocuses in measures for predicting costs and predictingdeaths.A primary care-oriented health system would prefer ameasure of predicting need for and use of specialtyservices. Starfield 04/07 CM 6712
  49. 49. Multimorbidity and Use of Primary and Secondary Care Services• Morbidity and comorbidity (and hence multimorbidity) are increasing.• Specialist use is increasing, especially for routine care.• The appropriate role of specialists in the care of patients with different health levels and health needs is unknown. Starfield 03/10 SP 7320
  50. 50. We know that 1. 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 subspecialist training of primary care MDs, the more the referrals. A MAJOR ROLE OF PRIMARY CARE IS TO ASSURE THAT SPECIALTY CARE IS MORE APPROPRIATE AND, THEREFORE, MORE EFFECTIVE.Source: Starfield et al, Health Aff 2005; W5:97-107. Starfield 08/05van Doorslaer et al, Health Econ 2004; 13:629-47; SP 6322
  51. 51. What is the right number of specialists? What do specialists do?What do specialists contribute to population health? Starfield 01/06 SP 6527
  52. 52. What We Do Not KnowThe contribution of specialists to• Unnecessary care (due to overestimation of the likelihood of disease)• Potentially unjustified care (due to inappropriateness of guidelines when there is comorbidity)• Adverse effects (from the cascade effects of excessive diagnostic tests) Starfield 11/05 SP 6503
  53. 53. What We Need to Know• What specialists contribute to population health• The optimum ratio of specialists to population• The functions of specialty care and the appropriate balance among the functions• The appropriate division of effort between primary care and specialty care• The point at which an increasing supply of specialists becomes dysfunctional Starfield 11/05 SP 6504
  54. 54. Aspects of Care That Distinguish Conventional Health Care from People- Centred Primary CareSource: World Health Organization. The World Health Report 2008: Starfield 05/09Primary Health Care – Now More than Ever. Geneva, Switzerland, 2008. PC 7123 n
  55. 55. ConclusionVirchow said that medicine is a socialscience and politics is medicine on a grandscale.Along with improved social andenvironmental conditions as a result ofpublic health and social policies, primarycare is an important aspect of policy toachieve effectiveness, efficacy, and equityin health services. Starfield 03/05 PC 6326
  56. 56. ConclusionAlthough sociodemographic factorsundoubtedly influence health, a primarycare oriented health system is a highlyrelevant policy strategy because itseffect is clear and relatively rapid,particularly concerning prevention ofthe progression of illness and effects ofinjury, especially at younger ages. Starfield 11/05 HS 6310
  57. 57. Strategy for Change in Health Systems • Achieving primary care • Avoiding an excess supply of specialists • Achieving equity in health • Addressing co- and multimorbidity • Responding to patients’ problems: using ICPC for documenting and follow-up • Coordinating care • Avoiding adverse effects • Adapting payment mechanisms • Developing information systems that serve care functions as well as clinical information • Primary care-public health link: role of primary care in disease prevention Starfield 11/06 HS 6457 n
  58. 58. Percentage of Visits in Which Patients Were Referred: US 1994 2006 Family medicine 4 8 Internal medicine 8 12 Pediatrics 3 6 Other specialties 3 5 Starfield 08/09Source: Valderas, 2009 NAMC analyses RC 7185 n
  59. 59. Family Physicians, General Internists, and Pediatricians A nationally representative study showed that adults and children with a family physician (rather than a general internist, pediatrician, or sub-specialist) as their regular source of care had lower annual cost of care, made fewer visits, had 25% fewer prescriptions, and reported less difficulty in accessing care, even after controlling for case-mix, demographic characteristics (age, gender, income, race, region, and self-reported health status). Half of the excess is in hospital and ER spending; one-fifth is in physician payments; and one-third is for medications. Starfield 03/09Source: Phillips et al, Health Aff 2009;28:567-77. PC 7103 n
  60. 60. Having a general internist as the PCP is associated with more different specialists seen. Controlling for differences in the degree of morbidity, receiving care from multiple specialists is associated with higher costs, more procedures, and more medications, independent of the number of visits and age of the patient. Starfield 08/09Source: Starfield et al, J Ambul Care Manage 2009;32:216-25. SP 7165
  61. 61. The greater the morbidity burden,the greater the persistence of anygiven diagnosis.That is, with high comorbidity,even acute diseases are morelikely to persist. Starfield 08/06 CM 6598
  62. 62. Results: Case-mix of Age Groups – Females Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7323 n
  63. 63. Results: Case-mix of Age Groups – Males Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7324 n
  64. 64. Results: Income Quintiles 25 20 % of sample 15 10 5 0 Q1 (Lowest) Q2 Q3 Q4 Q5 (Highest) SES quintiles Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7325
  65. 65. Results: Capitation Fee by SES 1.15 1.14 Mean capitation fee index 1.13 1.12 1.11 1.10 1.09 1.08 1.07 1.06 1.05 1.04 Q1 (Lowest) Q2 Q3 Q4 Q5 (Highest) SES quintiles Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7328
  66. 66. Results: Case-mix by SES - ADG 2.95 2.90 Mean ADG counts 2.85 2.80 2.75 2.70 2.65 2.60 Q1 (Lowest) Q2 Q3 Q4 Q5 (Highest) SES quintiles Starfield 03/10Source: Sibley L, Family Health Networks, Ontario 2005-06. CM 7326 n
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