There is a compelling association between comprehensive primary care and system efficiency and effectiveness. The lifelong work of the late Barbara Starfield observed that an investment in primary care was associated with improved system quality, equity and efficiency (reduced cost).
In British Columbia this efficiency was quantified by Marcus Hollander. The total cost of care was measured for the sickest patients. Patients without close alignment to primary care had a system cost of $30,000 per patient per year. Patients with close alignment to primary care had a system cost of $12,000 per patient per year.
Comprehensive primary care is the foundation of a sustainable, responsive health care system in Ontario. The goals of comprehensive primary care are to:
The focus of the primary care team is therefore to:
To be able to optimize performance of primary care teams, the foundation must be set to:
The key components of this model are as follows:
The expected benefits of implementing the Starfield Model:
The Starfield Model is named in honour of the late Barbara Starfield, researcher and champion of the value of strong primary care systems worldwide. Her name is used with permission from her family.
In Ontario, comprehensive primary care is often described by the Provincial Co-ordinating Committee on Community and Academic Health Science Centre Relations (PCCCAR) Basket of Services. Outside of this, there is no mention of the term in Ontario’s Action Plan for Healthcare, and passing mention in the Strategic Directions for Strengthening Primary Care report. The MOHLTC website on “your healthcare options” lists “walk-in clinic” as the first option!
The concept of comprehensive primary care is congruent with that of the Patient Medical Home. The US National Committee for Quality Assurance–Patient Centered Medical Home identified the key elements as follows:
AFHTO’s approach to primary care measurement focuses on the relationship with our patients and our ability to deliver the care patients value. Its objective is to optimize quality, access and total health system cost of care for patients, using indicators from Health Quality Ontario’s Primary Care Performance Measurement (PCPM) Framework.
An article describing the model and a case study of its implementation was published in Healthcare Management Forum – The Starfield model: Measuring comprehensive primary care for system benefit.
Barbara Starfield said, “Any country that is serious about primary care would eschew a sole focus on disease-oriented quality goals. Yet Canada has adopted lock, stock and barrel the ‘micro’, biomedically oriented approaches to quality, and payment for performance focused narrowly on diagnosis and management of specific diseases.”
To get a true picture of the quality of comprehensive primary care, one must consider the balance of multiple indicators at the same time. The PCPM framework includes many of the key indicators that are important for identifying the key attributes and services of comprehensive primary care; however the framework includes more than 50 measures grouped under 8 domains. It will be necessary to roll up individual measures into domain summary measures in order to maximize the usefulness of the PCPM framework for practices.
To facilitate comparisons between practices it will also be useful to develop an overall summary measure that includes all of the domains. To reflect the value of comprehensive primary care, it will be advisable to weight each measure according to its societal value. Appropriate weights could be established through a process that engages the public, patients, providers and decision-makers. The resulting domain and overall summary measures would then be useful measures of the value that comprehensive primary care has for society.