The pivotal role of primary care within the health system

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The pivotal role of primary care within the
health system

• André Knottnerus
• Utrecht, 13 October, 2006

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• The domain of primary care
• What is good primary care?
• Importance of good primary care
• European perspectives and challenges

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The domain of primary care
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It all starts with the patient (various studies
internationally)

• In period of 2 8 weeks
• 65 - 95 of people experience health problems
• for 10 25 of those professional help is
  sought
• Also potentially serious problems (chest pain,
  shortness of breath, and abnormal blood loss)
  mostly not presented
• Self care and lay care are substantial
• No reason to assume people consult too easily

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• Van de Lisdonk EH. Perceived and presented
  morbidity in general practice. A study with
  diaries in general practice. Scand J Prim Health
  Care 1989 7(2) 73-78

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Second National Morbidity Survey. Utrecht
NIVEL, 2004
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Spectrum selection from primary to specialist care
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• Symptom GP Referred
• Chestpain 14 CHD 50 CHD
• Lympha- 0.8 Ca 35-50 Ca
• denopathy

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• People do not consult unnecessarily
• Primary care is highly selective
• Differences in spectrum between primary and
  referred care
• Implications for health care provision

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What is good primary care?
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European primary care

• An advisory report of the Health Council of the
  Netherlands

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What is good primary care?

• encompasses general medical, paramedical and
  pharmaceutical care, nursing and general personal
  care, prevention and health-education
• is generalist care (also general mental and
  social healthcare)
• is provided close to/at home
• has a low access threshold
• is able to respond to urgent cases

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What is good primary care? (2)

• continuity in accountability and responsibility
• departs primarily from the demand for care
• but proactive responsibility in relation to
  prevention and health promotion
• provided by different care providers on a
  coordinated basis primary care team

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Importance of good primary care
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Evidence to support primary care being essential

• Primary process
• evidence-based primary care
• diagnosis, treatment, prognosis
• screening and prevention
• process
• continuity
• quality management, guidelines/standards
• (non)referral
• System
• degree of primary care orientation

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Primary process, e.g.,

• Proportionality risks of too highly specialised
  care and unnecessary hospitalisation
• Risks of unnecesary or too long immobilisation
• For many common problems, GP care is much more
  cost-effective than specialist referral
• For many problems, joint consultation of GP and
  specialist in primary care is much more
  cost-effective than direct referral
• Primary care based cervical screening, and
  influenza vaccination in the elderly reach very
  huigh coverage

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Importance of continuity(De Maeseneer et al. Ann
Fam Med 2003)

• Sample of 4800 persons from the registry of large
  Belgian health insurance companies
• Two years of follow-up
• Stronger adherence (continuity of care) in case
  of one and the same GP
• ? significantly less total healthcare cost
• Adjusted for important confounding variables

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Evidence gap, e.g., articles on RCTs, Medline
2004

• RCTs
• N
• Total 19590 100
• Primary care 353 1.8
• General practice 170 0.9

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Major evidence gaps

• Stop studies
• Interventions/devices/tools for which no formal
  effectiveness requirements exist
• Non-pharmacological interventions
• Diagnostics
• Medical aids
• Health advice

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Discrepancy health care volume primary care and
RCT evidence
health care volume
RCT evidence
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Primary Care International Comparisons
Barbara Starfield
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Primary Care Orientation of Health Systems
Rating Criteria

• Practice Characteristics, e.g.,
• First-Contact
• Patient lists
• Requirements for 24-hour coverage
• Longitudinality
• Comprehensiveness
• Coordination
• Family-centeredness
• Community orientation

adapted from Starfield B. Primary Care
Balancing Health Needs Services Technology,
1998 (Chapter 15)
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Primary-care score vs outcome indicators
(Starfield, Lancet 1994 344 1129 33)

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USA
GER

Primary care score ranking

BEL
AUS


6

SWE
CAN
SP


FIN
DK
NL

UK
0
5
10
Average rank for satisfaction, expenditures/head,
14 health indicators, and medications per
head. N.B. 1 is best, high is worse
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Primary-care score vs health-care expenditures
(Starfield, Lancet 1994 344 1129 33)
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UK

NL
DK
FIN
Primary care score

SP


1
AUS
CAN

SWE
BEL

GER

USA
0
1500
3000
Health-care expenditures per head
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Evidence summarised

• 90 or more of all health presented problems can
  be resolved in primary care
• characteristics of good primary care associated
  with favourable outcomes
• comparative studies of health care systems
  (Starfield, Macinko, Gulliford,OECD etc)
• strong primary care associated with
• good population health status
• low healthcare costs (cost-effectiveness)
• impact of primary care for whole system
• more international comparative research useful

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European perspectives and challenges
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Present situation in EU

• primary care generally available
• good accessibility in most countries
• variation with respect to
• degree of generalism
• competition of specialists
• registration with primary care facility
• gatekeeping
• financing system

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Challenges

• communication and navigation
• individualization and consumer expectations/demand
  s
• e-health
• continuity
• 24 hours
• longitudinal care
• public accountability
• scientific and technological developments e.g.,
• genomics
• home care technology

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Issues

• programmatic and integrated care tailormade
  collaboration with specialists
• responsibility for well-defined community
  (continuity, prevention)
• ? capitation fee incentives?
• tension between continuity and competitive
  healthcare?
• generalism versus task differentiation?
  Separating care and bureaucracy
• Evaluate structural and policy interventions
  (with international comparison)