Tuesday, March 15, 2005, 12:01 a.m. ET

Jon Gardner at Health Affairs

Death Rates Lower In Areas With More Primary Care Physicians,
But Not Specialists, Health Affairs Article Says

Inappropriate Tests And Procedures, Inadequate Volume Cited As Possible
Reasons Why Higher Specialist Ratio Does Not Lower Death Rates

BETHESDA, MD—Counties with a greater number of primary care physicians have a lower mortality rate, but having a greater number of specialists does not appear to lower the mortality rate, according to an article published today on the Health Affairs Web site.

Federal data on physician supply in more than 3,000 U.S. counties indicate that a higher ratio of primary care physicians to population results in lower mortality rates overall as well as for heart disease and cancer, according to the analysis by Barbara Starfield, a professor at the Johns Hopkins Bloomberg School of Public Health, and three colleagues. A higher ratio of specialists to population did not improve mortality rates, she says.

Starfield’s findings of the analysis could help guide lawmakers developing health care workforce policy.

“In view of the strong evidence that having more specialists, or higher specialist-to-population ratios, confers no advantage in meeting population health needs and may have ill effects when specialist care is unnecessary, increasing the specialist supply is not justifiable,” she says.

The analysis affirms an existing body of work that has documented no improvement in population health when the ratio of specialists is increased.

Starfield suggests several possible explanations for her findings:

— Patients may be receiving care from specialists outside their area of expertise, putting them at higher risk for mortality from community-acquired pneumonia, heart attacks, congestive heart failure, and upper gastrointestinal hemorrhage.

— Because higher volume is associated with better outcomes in surgery and other specialty procedures, a higher specialist-to-population ratio may mean that specialists are seeing fewer patients and thus are less proficient.

— Because specialists have a higher likelihood of suspecting serious disease as a result of their training, a higher specialist-to-population ratio may mean more unnecessary diagnostic workups, which puts patients at risk of medical errors.

Starfield’s coauthors are Leiyu Shi, an associate professor at the Hopkins public health school; Atul Grover, an instructor there; and James Macinko, an assistant professor of public health at New York University.

The research was supported in part by a grant from the federal Bureau of Primary Health Care.

Accompanying Starfield’s paper are perspectives by David Goodman, a professor at Dartmouth Medical School’s Center for the Evaluative Clinical Sciences; Robert Phillips Martey Dodoo, and Larry Green with the Robert Graham Center; and Edward Salsberg, director of the Center for Physician Workforce Studies at the Association of American Medical Colleges.

You can read Starfield’s article at content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97.

You can read Goodman’s perspective at content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.108.

You can read Phillips’ perspective at content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.111.

You can read Salsberg’s perspective at content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.115.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print, with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.



©2005 Project HOPE–The People-to-People Health Foundation, Inc.