May, 2012 - SUPPORT Summary of a systematic review | print this article |
General practice (primary care) provides entry for the majority of patients in many healthcare systems, and includes care for a wide range of common, often poorly-defined health problems. Primary care can be offered in health centres, hospitals or by independent physicians, and sometimes fulfills a gatekeeping function for access to specialist services. Reimbursements are usually made on a fee-for-service or capitation basis unless general practitioners are salaried employees. It has been argued that while the care offered by general practitioners is cheaper than specialist care it is also of lower quality.
Review Objectives: To find evidence of the cost-effectiveness and quality of the work done by physicians in primary care. | ||
/ | What the review authors searched for | What the review authors found |
---|---|---|
Interventions | Studies in which costs, quality and/or results in specialist care versus primary care were compared |
6 studies of primary care and its impact on health indicators 7 studies on primary care and costs in health care systems 6 studies on reimbursement systems 4 studies on the effects of gatekeeper systems 6 studies on the effects of continuity of care 6 studies on the effects of medical specialities in primary care 10 studies comparing quality of care in primary and specialist care |
Participants |
Individuals and populations. No limits with regard to study design (cohort, cross-sectional, case-control, RCT, reviews, database studies) |
31 studies focusing on individuals or events 4 studies comparing outcomes across populations (same country) 3 studies comparing outcomes across countries 7 literature reviews |
Settings | No restrictions |
OECD, majority from the United States of America (USA) and Western Europe |
Outcomes | Public health outcomes and proportion of health care resources allocated to primary care |
6 studies on public health outcomes and proportion of health care resources allocated to primary care 7 studies on total health care system expenditure and proportion of health care resources allocated to primary care 22 studies on performance/effects of primary care and ways of organising primary care 10 studies on differences in quality of and cost for care between primary and specialist care |
Date of most recent search: Not specified. | ||
Limitations: This review has important limitations with regard to the methods used to identify studies. Only studies published in English were included and reference lists were not checked. It is also not clear if multiple reviewers screened texts and extracted data or not. The date of the most recent search is not provided, and the review might be out-of-date given that it was published in 2001. The review is narrative and no weighing or quantification of the findings beyond that provided in the underlying publications is attempted. |
Engström S, Foldevi M, Borgquist L. Is general practice effective? A systematic literature review. Scand J Prim Healthcare 2001; 19:131-144.
A total of 45 publications, including literature reviews, studies comparing outcomes across countries or across populations, and studies focusing on individuals or events, were included. All studies were conducted in Organization for Economic Co-operation and Development (OECD) countries, mainly in the United States of America (USA) and Western Europe. The identified studies investigated the impact of primary care on health indicators and costs, compared reimbursement systems, evaluated the effects of gatekeeper systems, the continuity of care and medical specialities in primary care, and compared the quality of care provided by general practitioners and specialists.
Outcomes | Impact | No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
Public health outcomes and proportion of healthcare resources allocated to primary care |
- Increased availability of primary care is associated with lower mortality rates, increased life expectancy, lower (post) neonatal mortality rates, and a lower rate of low birth weight - Close association between ranking of primary care and 12 public health indicators and satisfaction/cost ratio - Lack of primary care doctor: OR 4.4 for severe uncontrolled hypertension |
(6 studies) |
|
Comparisons across States in the USA Comparisons across 10 countries Case-control study |
GRADE: GRADE Working Group grades of evidence (see above and last page) |
Compared to specialist care, primary care may reduce healthcare costs but may not lead to any differences in health outcomes
Outcomes | Impact | No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
Total healthcare system expenditure and proportion of healthcare resources allocated to primary care |
- Increased availability of primary care physicians reduces healthcare costs (in-hospital and out-of-hospital). Health outcomes are similar. - Primary care physician rather than specialist as personal physician results in 33% lower annual healthcare expenditure. - Primary care physician rather than hospital as primary source of care results in 35% less inpatient care and 50% fewer emergency room visits. - Ambulatory care episodes: 53% cheaper if started with personal primary care physician. - Low back pain: similar outcomes but 50% less cost if treated by primary care physician rather than specialist. |
(7 studies) |
|
Database studies of insurance claims, cohort and cross-sectional studies of individuals, literature review including 23 studies. |
GRADE: GRADE Working Group grades of evidence (see above and last page) |
Outcomes | Impact | No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
Performance/effects of primary care and ways of organising primary care |
Re-imbursement systems: Gatekeeper system: Single or group practices: Continuity of care: Medical specialities in primary care: |
(22 studies) |
Cohort and cross-sectional studies, medical record review Cross-country comparisons, RCTs Cohort study Literature review, cohort studies, insurance claims review Database study of medical records, RCTs, cross-sectional and cohort studies |
|
GRADE: GRADE Working Group grades of evidence (see above and last page) |
Outcomes | Impact | No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments |
Differences in the quality and cost of care between primary and specialist care |
- No difference in the quality of diabetes, hypertension, low back pain and depression management between primary and specialist care. - Management by GPs reduces costs by 30-40% with no apparent effects on outcomes. |
(10 studies) |
|
RCTs, cohort studies, medical record review, literature reviews |
GRADE: GRADE Working Group grades of evidence (see above and last page) |
Findings | Interpretation* |
---|---|
APPLICABILITY | |
All included studies were conducted in high-income countries. |
Primary care is a component of virtually all healthcare systems because care for minor health issues needs to be provided in a decentralised way. Hence, at least some of the findings from this study are likely to be valid in LMICs as well. Conclusions derived from studies of primary care delivered by physicians in HICs may not be directly applicable to LMICs due to structural differences in healthcare options, education and resources. |
EQUITY | |
The review did not discuss equity-related issues. |
Primary care could improve equity by lowering financial and institutional access barriers to healthcare. The resources saved could be employed to improve equity. |
ECONOMIC CONSIDERATIONS | |
Primary care may reduce healthcare costs compared to the health costs of specialist care. |
The cost-savings associated with primary care are arguably more relevant in resource-constrained settings and could result in disproportionally positive public health effects if savings are invested in boosting healthcare. Boosting primary care usually results in lower overall healthcare resource usage (diagnostic tests, drugs, hospitalisations, specialist appointments etc.). Establishing a primary care system requires additional resources, specifically for the training of general practitioners, public information and education and, if unavailable, healthcare infrastructure (such as health centres etc.). |
MONITORING & EVALUATION | |
The review found evidence from a substantial array of sources for the financial and public health benefits of primary care in high-income countries. |
The absence of evidence on the effectiveness of general care from LMICs calls for comprehensive monitoring and evaluation if primary care is introduced/expanded/emphasised. All areas (financial, public health, health outcomes, patient satisfaction, organisational etc.) need to be monitored and evaluated. |
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy. 2001; 6:44-55.
Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002215. DOI: 10.1002/14651858.CD002215.
Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004015. DOI: 10.1002/14651858.CD004015.pub3
Starfield B. Is primary care essential? Lancet 1994;344:1129 – 33.
WHO. Alma Ata 1978. Primary Health Care. Report of the International Conference on Primary Health Care. Geneva: WHO; 1978.
This summary was prepared by
Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland.
Conflict of interest
None declared. For details, see: www.support-collaboration.org/summaries/coi.htm
Acknowledgements
This summary has been peer reviewed by: Sven Engström, Sweden; Julie Cliff, Mozambique.
This summary should be cited as
Steinmann P. Is general practice effective? A SUPPORT Summary of a systematic review. May 2011. www.support-collaboration.org/summaries.htm
Keywords
All summaries: evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low- and middle-income countries, developing countries, primary health care, specialist care, general practitioner, cost, health outcomes, capitation, fee-for-service, gatekeeper.