Summary of Achievements in Primary Care Research
In 1978, the World Health Organization proposed a strategy for achieving Health For All. Widely considered a seminal document for developing an ethical basis for health services worldwide, its philosophical tone and absence of specific strategies made it an easy target for manipulation in a world in which health services were becoming increasingly market-oriented, technologic, and impersonal.
At the same time as it became evident that international lending agencies were failing to improve the availability of health services for populations that could not afford to pay for them, evidence of the importance of primary care was being developed. The work of the Primary Care Policy Center (PCPC) at the Johns Hopkins Bloomberg School of Public Health was critical in producing this evidence. Over a period of 15 years, the Center, originally supported by the Bureau of Primary Health Care in the U.S. government, has produced most of the worldwide evidence of the benefits of primary care-led health systems, both in the United States and internationally. Primary care is person- and population-focused care with provision of accessible, comprehensive, and coordinated services as its hallmarks. It is distinguished by its orientation to overall health and illness experiences of people, rather than only toward biomedical characteristics of diseases. The Center's landmark 2005 paper summarized all of the evidence to date that primary care-led health systems produce greater effectiveness of health services with reductions in disparities in health across population subgroups, and at lower costs than health systems oriented toward disease-focused, specialty-dominated health systems.
As was true of the PCPC’s cofounder, the late Dr. Barbara Starfield, the current principals of the PCPC, Drs. Leiyu Shi and James Macinko, are world renowned and continue to serve as informal advisers to governments and professional groups, particularly those concerned with building stronger primary care infrastructures in their health systems. These countries include, but are not limited to, Australia (where the primary care legislation specifically mentions the work done by th Center), New Zealand, Sweden, Lithuania, the United Kingdom, Spain, Brazil, South Africa, Thailand, Malaysia, Bulgaria, Canada, Chile, Argentina, and, most recently, Oman and Italy.
The landmark Pan American Health Organization document, Primary Care in the Americas, was based largely on evidence produced and summarized by the PCPC; the committee that launched it was co-chaired (with the deputy director of PAHO) by Dr. Starfield and staffed by Dr. Macinko. The report served as one basis for the 2008 World Health Report of the World Health Organization, for which Dr. Starfield served as reviewer and adviser.
Invitations to present at major international forums on the subjects of primary health care, equity in health care and health, and chronic diseases in the context of social and societal influences on health have increased in both number and frequency; international presentations in the most recent two years are listed below.
- Global trends on the primary health care strategy. Renewal of the Primary Health Care Strategy. Barbados. May 9-10, 2011.
- Measuring primary care: theory, policy, and practice. Southby Lecture, George Washington University. Washington, DC. April 21, 2011.
- Multimorbidity and the nature of disease. Zaragoza, Spain. March 8, 2011.
- Equity in health services and health. WONCA Regional Meeting: Asia/Pacific. Cebu, Philippines. February 24, 2011.
- PCAT: history, development, and application. WONCA. Cebu, Philippines. February 2011.
- Primary healthcare: the worldwide imperative for, and challenges of, health system reform. Qatar Health. December 15, 2010.
- Research Proposal Writing. Johns Hopkins University course 300.870. Baltimore, MD. November 10, 2010.
- Primary Care Assessment – the PCAT. Montevideo, Uruguay. November 2010.
- Health systems based on primary care. International Seminar on Assessment of Primary Health Care. Montevideo, Uruguay. November 4, 2010.
- Increasing primary health care effectiveness. Durban, South Africa. October 31, 2010.
- Primary care/specialty care in an era of mutimorbidity. ACGs: One System, Many Nations. 2010 ACG International User Conference. Tucson, Arizona. May 9-12, 2010.
- Prevention, public health, and equity. Sommer Memorial Lecture. Oregon Health and Science University. Portland, OR. May 2010.
- Diseases, chronic care, and primary care. Sommer Memorial Lecture. Oregon Health and Science University. Portland, OR. May 2010.
- Benefits of primary care. Sommer Memorial Lecture. Oregon Health and Science University. Portland, OR. May 2010.
- Primary care/specialty care in the era of multimorbidity. 19th WONCA World Conference of Family Doctors. Cancun, Mexico, May 19-23, 2010.
- Primary care/specialty care in the era of multimorbidity. Herbert Vaughn Lecture. Boston, MA. May 2010.
- Primary care: its role in healthcare reform. Herbert Vaughn Lecture. Boston, MA. May 2010.
- Combating overuse and expensive and unnecessary services through primary care. COGME. Washington, DC. April 22, 2010.
- Organization and delivery of primary care services. Martin’s Point Health Care: Innovations Leaders Series. Portland, Maine. April 14, 2010.
- Primary care in the 21st century. Portland, ME. April 2010.
- The renewal of primary care: an international scenario and principal challenges. International Meeting on Primary Health Care. Sao Paulo, Brasil. April 7, 2010.
- Primary (health) care: the new worldwide imperative. University of Toronto Medical Grand Rounds. Toronto, Canada. January 19, 2010.
- Assessing the adequacy of primary care: What indicators? CIHR Primary Healthcare Summit Toronto, Canada. January 18, 2010.
- Advancing Research on Vulnerable Populations. Presented at the Research Salon organized by Sun-Yat-sen University medical campus, Sun-Yat-sen University. Guangzhou, People’s Republic of China. November 17, 2011.
- Significance of Barbara Starfield’s Work to the Field of Primary Care: The Impact of Primary Care on Population Health and Health Equity. Presented at 2011 APHA 139th Annual Meeting and Exposition. Washington, DC. October 31, 2011.
- Promoting Primary Care to Improve Population Health. Presented at Symposium on Primary Care Development in China, Peking University China Health Development Research Center. People’s Republic of China. October 11, 2011.
- Reforming US Healthcare Delivery: Implications for China. Presented at the Public Health Leadership Training Workshop for Deans of School of Public Health in China. Beijing, China. March 23, 2011.
- Reforming US Healthcare Delivery. Presented at the International Conference on Health Care Reform: Asia-Pacific Experiences and Western Models, The Chinese University of Hong Kong Institute of Asia Pacific Studies. Hong Kong. March 4, 2011.
- US Healthcare Delivery: Current Status, Challenges, and Strategies to Improve. Presented for the School of Community Health and Policy, Morgan State University. Baltimore, MD. November 16, 2010.
- Advancing Primary Care to Improve Community Health. Presented at the 2010 Taiwan Taoyuan County Urban Health and Public Health Symposium. Taoyuan, Taiwan. October 23, 2010.
- Current Status and Challenges of U.S. Health Care Management: Implications for Hospital CEOs from China. Presented at the 2010 Chinese Hospital CEO Training Workshop. Baltimore, MD, October 4, 2010.
The time is opportune to build an even more effective force for leadership by the PCPC. Changes in the world's appreciation of the benefits of primary care now make it possible to move forward in expanding the staff, activities, and capacity of the PCPC to contribute even further to providing the evidence base for effective change in health systems, both in the U.S. and abroad. Much remains to be learned in order to meet the new challenges to health services: patient- and population-orientation rather than a sole focus on specific diseases or risk factors; improving responsiveness of health professionals and systems to the problems experienced by patients and populations; moving faster and further to reduce disparities in health across population groups characterized by gender, socioeconomics, race, and ethnicity; and making health services safer and more effective in dealing with health problems.
The proposed expansions are in the following areas:
- Apply knowledge of the benefits of primary care to consideration of the imperatives of chronic care and chronic illness.
- Consider application of primary care principles to care of the elderly and to the challenges of health problems of the aging.
- Better rationalize and achieve, through primary care, the relative priorities of preventive care, care of acute and chronic illnesses, and palliation.
- Develop and apply ways of characterizing morbidity burdens of populations that allow better targeting of both primary care and specialist care resources to meet the health-related needs of populations and patients.
- Assessment of the adequacy of achieving primary care attributes by patient-centered medical home (PC-MH) demonstrations and developments.
- Assessment of progress, both intra-nationally and internationally, in developing primary care-oriented health systems and services
Accomplishments of the Primary Care Policy Center
Unique strengths and capabilities of the Johns Hopkins team:
- The Johns Hopkins PCPC was created through the financial support of the BPHC. Since its inception in 1996, the PCPC has carried out studies and analyses for the BPHC. The investment by the BPHC has reaped significant results, as evidenced by the number of rigorous scientific publications and studies conducted through the Johns Hopkins PCPC.
- Contributions specifically pertinent to the work of health centers: The Johns Hopkins team has produced the most literature on the nation's vulnerable populations, in particular on health centers that serve vulnerable populations, including their sustainability, provider recruitment and retention experiences, financial performance, experience under managed care, preventive care services, quality of care, and comparisons with other healthcare settings.
- Contributions to knowledge and policy concerning primary care: The PCPC team has conducted pioneering research on the association between primary care and health outcomes, the role of primary care in reducing social inequities, and, more particularly, on the role of primary care in mediating the adverse impact of income inequality on health outcomes, in collaboration with BPHC colleagues and other national experts. Studies have been conducted using U.S., state, MSA, county, and individual level data. Since both income inequality and primary care are significantly and independently associated with health indicators, the policy implications are broadened beyond efforts at improving income equality. This is particularly relevant in the U.S., where reduction of income inequality is not a social priority and where characteristics of the market and political economy are inimical to income redistribution. The promotion of primary care is one potential policy strategy to improve health, even in the face of marked disparity in the distribution of income. The Johns Hopkins team has been involved in the development and validation of adult-, child-, and practice/facility-specific primary care assessment tools that capture the principal domains of primary care. These tools can be used to study primary care experience rendered under different health care systems or settings, and for patients with different sociodemographic attributes.They can be used with other outcomes to assess the effect of policy interventions and system changes on the delivery of critical aspects of primary care. Dr. Shi is a national leader in the research on primary care and health inequities.
- The Johns Hopkins team has a strong and nationally known clinical expertise. Not only are the core investigators primary care clinicians and researchers, we have access to nationally known clinical researchers of all specialties. The Johns Hopkins University Adjusted Clinical Groups (originally "Ambulatory Care Groups") Case-Mix System is the nation's most widely used and tested, population-based risk-adjustment tool. The ACG Case-Mix System is a person-focused method of categorizing patients' illnesses. Over time, each person develops a constellation of conditions. Based on the pattern of these morbidities, the ACG approach assigns each individual to a single group (an "ACG"), which permits the effects of a clustering of morbidities to be captured in estimates of resource use. With its strong clinical expertise and ACG technology, the Johns Hopkins team is uniquely positioned to study health center patients and appropriately compare them with national patients.
- Extensive knowledge of and experience with data sets: The PCPC has worked extensively with both health center data sets and other national sources of data, including survey data, health services data, and population data on health and resources. Intimate knowledge of these data sets makes it possible to conduct comparative analyses and also to extend analyses to include more and other increasingly relevant characteristics relating to health.
- Direct input of research into policy streams: The contributions achieved in collaboration with the BPHC have relevance far beyond their pertinence to the work of health centers. Research and analyses using health center data, both by themselves and in comparison with other types of sources of care, contribute to decision making throughout the U.S. and abroad. Results from these studies and analyses have been presented both in published media and prestigious peer-reviewed journals, as well as in numerous forums nationally and internationally. Because of the extensive research, the principals of the PCPC are increasingly called upon to meet with decision makers in various countries. Legislation to improve primary care and executive actions to strengthen primary care have been based heavily on findings of studies in which the PCPC and the BPHC have collaborated. This is the case for industrialized countries such as the U.K., Ireland, Australia, New Zealand, and Spain, as well as developing countries such as Brazil. Continuing and new initiatives of the Administration, and of the Health Resources and Service Administration (HRSA) within it, have available to them evidence that appropriate primary care, as represented by health centers, is associated with reduced disparities across racial and ethnic groups as well as across socioeconomic strata – directly as a result of evaluations and analyses conducted by the PCPC.
- Relevance of PCPC work to current and future imperatives: Several challenges are increasingly being posed to the U.S. health services system including health personnel policy, policies regarding referrals from primary care to secondary and tertiary care, adequacy of specialty care, pay for performance as a result of improvement in quality, and disparities in health across population subgroups. The PCPC is immediately poised, as a result of its extensive work on current health care concerns, to embark on these new and emerging areas.
- Areas for expansion, given appropriate resources: PCPC personnel have the capacity to expand into new areas as they become of high priority. Within the past year, questions have been raised about the adequacy of the number of primary care physicians and specialists in the U.S. Prior work done by the PCPC has provided initial information to inform decisions in this area. Expansions, however, are possible in several areas.
- The role of non-physician personnel in providing adequate primary care: A sizable number of practitioners in health centers are non-physicians. Yet little is known about the balance of types of care provided by physicians and non-physicians, and their relative achievement of high quality care with good outcomes.
- A second area for expansion is referral policy. The PCPC has already produced information on the nature of referrals, and of specialty care in the U.S., and has shown that there are considerable concerns about appropriateness, particularly with regard to overuse and potential adverse effects of unnecessary care. Given the difficulties health centers often face in finding back-up specialty care for their patients, this subject is of very high relevance to the health care they provide to patients.
- A third area for expansion concerns disparities in health care. Several reports by the Institute of Medicine document inequalities in care received by many minority populations. These analyses have, for the most part, been unable to control adequately for underlying health status. As a result of work done in related units of the department in which PCPC is housed, we are able to describe and characterize overall morbidity burdens (as well as specific disease burdens) in populations. Tools developed by the PCPC could be increasingly applied to analyses of BPHC data.
- The fourth area in which expansion is possible concerns dissemination activities. In conjunction with the BPHC, the PCPC should explore more extensive contacts with media and policymakers, as well as consumer groups, to provide global leadership to inform health policy in wealthy, middle-income, and low-income countries; to produce evidence-based information on the design of health systems around a primary care infrastructure; and to document the effectiveness and efficiency of primary care-oriented health systems and their critical importance to improving equity in health and reducing socioeconomic, racial, ethnic, gender, and other disparities.