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Introduction : In the definition of primary care put forward by Dr. Barbara Starfield, primary care refers those health-related needs of people “too uncommon to maintain competence and coordinates care when people receive services at other levels of care” (1) Patients with poorly coordinated care are likely to have more costly and lower quality health care due to factors such as excess utilization resulting from redundant investigations, potentially harmful missed drug-disease interactions, and lower patient satisfaction. Therefore, the identification of patients at risk of poor coordination is essential. This presentation will address the impact of information on improving coordination of care across the spectrum of the health care and community services systems. As morbidity burden increases the number of different clinicians seen rises(2), yet coordination of care is threatened when information does not readily flow between those involved in delivering care. Case-mix tools which transform routinely collected electronic health data into actionable information can support both the clinician's decision making process and the policymaker to provide better coordinated care through the exchange of clinical data, measurement of patients’ needs, and a better understanding of the use of healthcare resources. Thus the imperative for coordination requires that all information generated in the care of patients be captured in the care provided over time. Theory / Method : The Johns Hopkins ACG® System has developed four complementary coordination markers as well as a coordination risk score to systematically assess the risk of poor coordination of care. In combination, the markers can identify populations at risk for poor coordination which has implications for cost, quality, and performance assessment. Greater insight about the convergence of risk, medical utilization and prescribing patterns can be captured by combining risk defined by diagnoses with risk defined by pharmacy information. Further, studies have shown that when clinicians share patients with other clinicians more frequently, they are more likely to have referral relationships and seek advice. With the release of Version 11, the ACG System introduced a measure of patient sharing among physicians, termed “Care Density”. This patient-level measure assesses the number of individual clinicians a patient sees and the degree to which those clinicians share other patients. The care density measure is based on the hypothesis that patients seen by clinicians who share patients more frequently have higher levels of communication and information sharing. (3,4) Results : An initial study of the Care Density measure on 9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes (DM) demonstrated a significant correlation between lower inpatient costs and rates of hospitalization amongst those patients with high care density. Also, for diabetic patients with high care density, lower outpatient costs and higher pharmacy costs were found.(3) A more recent study of the Care Density measure expanded its population size to 1.7 million patients with CHF, COPD and/or Diabetes. Among all patients, patients with the highest care density—indicating high levels of patient-sharing among their office-based physicians— had significantly lower rates of adverse events measured as Prevention Quality Indicators (PQIs) compared to patients with low care density (Odds Ratio [OR] 0.88, 95% Confidence Interval [CI] 0.85-0.92). A significant association between care density and PQIs was also observed for patients with DM but not CHF or COPD.(4) Diabetic patients with higher care density scores had significantly lower odds of 30-day readmissions (OR 0.68, 95%CI 0.48-0.97). Significant associations were observed between care density and HEDIS measures though not always in the expected direction.(4) Discussion & Conclusion : Through a better understanding of how patients are shared amongst clinicians, as well as identifying those patients at risk of uncoordinated care, coordination can be improved, rates of hospitalization reduced and potential cost savings achieved. Further research is necessary to substantiate these results in other health care settings. References: 1- Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press. 1998. 2- Starfield et al, J Am Board Fam Pract 2002;15:473-80 3- Pollack, et.al, Care Density and Costs of Care, J Gen Intern Med 2013;28(3):459-65. 4- Pollack, et.al, Patient sharing and quality of care: measuring outcomes of care coordination using claims data. Med Care 2015;53:317-323.

OBJETIVO: Determinar la validez y la fiabilidad de los "instrumentos para evaluar la atención primaria de salud" (Primary Care Assessment Tool [PCAT, por su siglas en inglés]), versión dirigida a usuarios adultos, adaptada para Argentina (AR-PCAT-AE). MÉTODOS: Se realizaron dos estudios piloto transversales con personas mayores de 17 años, mediante cuestionarios mayoritariamente autoadministrados. Se analizaron los ítems equivalentes a la versión original de los PCAT y otros 13 propuestos para ser adicionados. Se examinó la validez factorial y la fiabilidad de las puntuaciones de cada dimensión. Los indicadores de validez fueron: factores que tuvieran tres o más ítems con una carga factorial >0,35, correlación ítem-total >0,30 e interpretación de la solución en consecuencia con el modelo teórico. RESULTADOS: El análisis factorial resultó en nueve factores que explicaron 57,4% de la variabilidad. Considerando los criterios de validez preestablecidos, se excluyeron dos ítems de las dimensiones de continuidad e integralidad y se adicionaron seis en integralidad y competencia cultural. En las dimensiones, el porcentaje de preguntas con correlación ítem-total mayor de 0,30 osciló entre 67% y 100% y el coeficiente de consistencia interna alfa de Cronbach entre 0,44 y 0,90. CONCLUSIONES: El cuestionario AR-PCAT-AE tiene validez y fiabilidad adecuadas, manteniendo una alta equivalencia con la versión original. El proceso presentado podría ser adoptado en otros contextos para avanzar en la necesidad de evaluar las funciones de la atención primaria con herramientas de calidad.OBJECTIVE: To determine the validity and reliability of the version of the Primary Care Assessment Tool for adult users, adapted for Argentina (known as AR-PCAT-AE). METHODS: Two cross-sectional pilot studies were conducted among people over age 17, largely through self-administered questionnaires. Items that were equivalent to the original version of the PCAT and 13 others proposed for the instruments were analyzed. The factorial validity and reliability of the scores for each dimension were studied. The validity indicators were: factors that had three or more items with a factorial load of > 0.35, item-total correlation > 0.30, and interpretation of the solution according to the theoretical model. RESULTS: The factorial analysis yielded nine factors that explained 57.4% of the variability. Considering the pre-established criteria for validity, two items were excluded from the dimensions of continuity and comprehensiveness and six were added to comprehensiveness and cultural competency. In the dimensions, the percentage of questions with an item-total correlation of greater than 0.30 ranged from 67% to 100% and the Chronbach's (alpha) coefficient of internal consistency ranged from 0.44 to 0.90. CONCLUSIONS: The validity and reliability of the AR-PCAT-AE questionnaire are adequate, maintaining high equivalence with the original version. The process presented could be adopted in other contexts to advance the evaluation of primary health care functions with quality tools.

BACKGROUND AND OBJECTIVES: The 2010 Affordable Care Act mandates that health insurance companies make those up to age 26 eligible for their parents’ policies. Thirty-four states previously enacted similar laws. The authors sought to examine the impact on access to care of state laws extending eligibility of parents’ insurance to young adults. METHODS: By using a difference-in-differences analysis, we examined the 2002–2004 and 2008–2009 Behavior Risk Factor Surveillance System to compare 3 states enacting laws in 2005 or 2006 with 17 states that have not enacted laws on 4 outcomes: self-reported health insurance coverage, identification of a personal physician/clinician, physical exam from a physician within the past 2 years, and forgoing care in the past year due to cost. RESULTS: For each outcome there was differential improvement among states enacting laws compared with states without laws. Health insurance differentially increased 0.2% (95% confidence interval [CI], −3.8% to 4.2%), from 67.6% to 68.1% pre-post in states enacting laws and from 68.5% to 68.7% in states without. Personal physician/clinician identification differentially increased 0.9% (95% CI −3.1% to 5.0%), from 62.4% to 65.5% in states enacting laws and from 58.0% to 60.2% in states without. Recent physical exams differentially increased significantly 4.6% (95% CI, 0%–9.2%), from 77.3% to 81.2% in states enacting laws and from 76.2% to 75.5% in states without. Forgone care due to cost differentially decreased significantly 3.9% (95% CI, −0.3% to −7.5%), from 20.4% to 18.2% in states enacting laws and from 17.8% to 19.4% in states without. CONCLUSIONS: States that expanded eligibility to parents’ insurance in 2005 or 2006 experienced improvements in access to care among young adults.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited., Commentary June 2010 marked the 10th Anniversary of the foundation meeting of the International Society for Equity in Health (ISEqH). The formation of the Society was a bold statement, with ambitions to be a global body "to promote equity in health and health services internationally through education, research, publication, communication and charitable support"[1]. The Society particularly aimed to be an organisation that facilitated research on how better to understand and address inequities in health. The main activities of the Society have been a series of biannual conferences as well as the establishment of the International Journal for Equity in Health, the official (but independent) publication of the Society. This paper sets out to record some of the milestones of the Society drawing on the reflections of key researchers who attended the conferences as well as others. The history of the Society will help shape its future and how it responds to important issues facing all interested in global efforts to address continuing and unacceptable inequities in health.

Background The main goal of Hong Kong's publicly-funded general outpatient clinics (GOPCs) is to provide primary medical services for the financially vulnerable. The objective of the current study was to compare the primary care experiences of GOPC users and the users of care provided by private general practitioners (GPs) in Hong Kong via a territory-wide telephone survey. Methods One thousand adults in Hong Kong aged 18 and above were interviewed by a telephone survey. The modified Chinese translated Primary Care Assessment Tool was used to collect data on respondents' primary care experience. Results Our results indicated that services provided by GOPC were more often used by female, older, poorer, chronically-ill and less educated population. GOPC participants were also more likely to have visited a specialist or used specialist services (69.7% vs. 52.0%; p < 0.001), although this difference in utilization of specialist services disappeared after adjusting for age (55.7% vs. 52.0%, p = 0.198). Analyses were also performed to asses the relationship between healthcare settings (GOPCs versus private GPs) and primary care quality. Private GP patients achieved higher overall PCAT scores largely due to better accessibility (Mean: 6.88 vs. 8.41, p < 0.001) and person-focused care (Mean: 8.37 vs. 11.69, p < 0.001). Conclusions Our results showed that patients primarily receiving care from private GPs in Hong Kong reported better primary care experiences than those primarily receiving care from GOPCs. This was largely due to the greater accessibility and better interpersonal relationships offered by the private GPs. As most patients use both GOPCs and private GPs, their overall primary care experiences may not be as different as the findings of this study imply.

PURPOSE We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States. METHODS We used data from the World Health Organization and from the American Medical Association Physician Masterfi le to gather sociodemographic, health system, and health characteristics of countries and the number of interna- tional medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States. RESULTS Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more special- ists to the US physician workforce. CONCLUSION The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign med- ical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.

ObjetivoReducir, traducir y adaptar transculturalmente la versión corta del cuestionario PCAT para usuarios (PCAT consumer client version) con el fin de conseguir una versión abreviada del instrumento original, en catalán y castellano, para su uso en la población española que sea de utilidad para incluir en las encuestas poblacionales de salud.DiseñoTraducción y adaptación de un cuestionario.EmplazamientoAtención primaria.MedicionesFases: a) selección de preguntas; b) adaptación transcultural de las preguntas seleccionadas mediante traducción directa al castellano y catalán e inversa al inglés, y c) la claridad, la aceptabilidad y la familiaridad del contenido de las 2 versiones pretest de los cuestionarios fueron evaluadas mediante entrevistas cognitivas a personas de diferentes perfiles de la población diana.Resultados principalesSe seleccionaron 15 preguntas para la versión para personas adultas y 24 para la versión para menores de 15 años, que permiten identificar a un proveedor de atención primaria de salud y recoger información sobre las dimensiones del primer contacto, la continuidad, la extensión y la coordinación.ConclusiónLos elementos seleccionados permitirán evaluar el grado en que la atención primaria de salud cumple con sus atributos esenciales de ser el primer contacto del usuario con los servicios sanitarios, mantener la continuidad de la atención, coordinar la atención sanitaria, y disponer y proveer servicios considerados necesarios en este ámbito. Adicionalmente, se podrá evaluar también su competencia cultural. Son elementos factibles de introducir en encuestas de salud.ObjectiveTo reduce, translate, and adapt transculturally, the short version of the PCAT questionnaire for users (PCAT Customer client version), in order to achieve an abbreviated version of the original instrument in Catalan and Castilian that is conceptually similar to the English original, culturally adequate and viable for use among the Spanish population, and useful for inclusion in the health surveys.DesignTranslation and adaptation of one questionnaire. Three steps were followed: a) question selection; b) transcultural adaptation of the selected questions, by means of direct translations to Castilian and Catalan with subsequent re-translation to English; c) clarity, acceptability, and familiarity with content of the 2 pretest questionnaire versions were evaluated through cognitive interviews of persons with different profiles in the targeted population.ResultsFifteen questions were selected for the adult version and 24 for the

ResumenObjetivoEl perfil de salud CHIP-AE (Child Health and Illness Profile, Adolescent Edition) es un instrumento genérico para adolescentes de 12 a 19 años que ha sido adaptado para uso en España. El objetivo del estudio fue obtener los valores poblacionales de referencia de la versión española del CHIP-AE.MétodosSe administró el CHIP-AE a una muestra representativa de adolescentes escolarizados de Barcelona, mediante muestreo por conglomerados, estratificado según la titularidad del centro (público o concertado) y el índice de capacidad económica familiar (bajo, medio y alto). Se estandarizaron las puntuaciones a una media de 20 y desviación estándar (DE) de 5. Se calcularon las medias y los percentiles. Las medias se compararon por edad, género y nivel socioeconómico mediante análisis de la varianza.ResultadosLas proporción de respuesta fue del 81% (n = 902). Las puntuaciones presentaron un amplio rango de distribución, y aunque en general fueron algo sesgadas hacia las puntuaciones de buena salud, sugieren que la muestra de población general no está exenta de problemas de salud. El 25% presentó puntuaciones por debajo de 17,2 en la dimensión de bienestar, lo que indica un tamaño de efecto de 0,56 unidades estandarizadas de DE. La distribución de las puntuaciones de las muestras de referencia de Barcelona fueron muy similares a las originales de Baltimore (Estados Unidos), con diferencias mínimas en riesgo individual.ConclusionesEl CHIP-AE recoge de manera sistemática las dimensiones propias de la salud de los adolescentes. Los resultados permitirán establecer comparaciones con adolescentes de otras regiones, y/o con diferentes problemas de salud y analizar las desigualdades en salud durante la adolescencia.AbstractAimThe Child Health and Illness Profile (CHIP-AE) is a generic health status instrument for adolescents aged 12-19 years adapted for use in Spain. The aim of this study was to obtain reference population values of the Spanish version of the CHIPAE.MethodsThe CHIP-AE was administered to a representative sample of adolescents from schools in Barcelona. The sample was selected by using cluster-sampling, stratified by type of school (public or private) and an ecological socioeconomic index (Índice de Capacidad Familiar: low, middle, and high). The CHIP-AE scores were standardized to a mean of 20 and a standard deviation (SD) of 5. Means and percentiles were computed. Means were compared by age, gender, and socioeconomic status using analysis of variance.ResultsThe response rate was 81% (n = 902). The distribution of the CHIP-AE scores presented a wide range with scores generally skewed toward positive health status. Nevertheless, the results suggest that the sample selected from a general population was not free of health problems. Twentyfive percent of adolescents presented scores below 17.2 in the domain of discomfort, indicating an effect size of 0.56 standardized SD units. The distribution of scores in the reference samples from Barcelona was similar to the original results in Baltimore (USA), with some marginal differences in individual risks.ConclusionsThe CHIP-AE systematically gathers information on health domains in adolescents. The results from this reference sample will allow comparisons with adolescents from other regions, and/or with different health problems, as well as description of inequalities in health during adolescence.

Six primary care practices which utilize both physician and non-physician practitioner types were studied to measure differences between practitioner types in the care of patients. By chart review 1,369 patient-practitioner encounters were examined. Physicians identified less symptoms and signs in their patients and prescribed less non-drug therapies than did non-physicians. Likewise, at follow-up visits, physicians tended to document less follow-up of these types of problems and therapies than non-physicians. When examining the interaction between practitioners, the highest rates of follow-up of all types of problems and therapies were found when the same practitioner saw the patient at two successive visits to the same clinic. When a physician saw a patient following a previous visit to a nurse practitioner, there was a significant drop-off in the follow-up rate of problems and therapies. However, when a nurse practitioner saw the patient following a previous visit to a physician, the drop-off in follow-up rates was not as striking. These findings indicate that the skills of physician and nonphysician practitioners are potentially complementary. However, this potential is not fully exploited, particularly by physicians.

The Baltimore City Primary Care Study examined the role of the urban office-based physician in the delivery of primary care. During the course of the study, questionnaires were completed by over 90 per cent of licensed physicians in the city, and data were collected from a sample of 16,000 patients. The study developed and assessed three approaches for the measurement of primary care. An empirical method was based upon information regarding the following characteristics of each visit: first contact visit, referral visit, specialized care visit, or principal care visit. A normative method was based on an assessment of the degree to which the practice provided care that was comprehensive, longitudinal, accessible, and family-centered. The third method used physicians' judgments as to the proportion of patients for whom they maintained ongoing responsibility for general medical care. All three methods produced the same categorization of different specialties as providing either primary, intermediate, or specialty care. As a group, primary care physicians included general and family physicians, pediatricians, and general internists. General surgeons and obstetrician/gynecologists have characteristics of both primary care and specialist care. All other physician groups have characteristics of specialists. Any of these methods or a combination of methods can be used to assess the extent to which the practice of a particular physician or group of physicians provides primary care.

Background Analyzing social differences in the health of adolescents is a challenge. The accuracy of adolescent's report on familial socio-economic position is unknown. The aims of the study were to examine the validity of measuring occupational social class and family level of education reported by adolescents aged 12 to 18, and the relationship between social position and self-reported health. Methods A sample of 1453 Spanish adolescents 12 to 18 years old from urban and rural areas completed a self-administered questionnaire including the Child Health and Illness Profile-Adolescent Edition (CHIP-AE), and data on parental occupational social class (OSC) and level of education (LE). The responsible person for a sub-sample of teenagers (n = 91) were interviewed by phone. Kappa coefficients were estimated to analyze agreement between adolescents and proxy-respondents, and logistic regression models were adjusted to analyze factors associated with missing answers and disagreements. Effect size (ES) was calculated to analyze the relationship between OSC, LE and the CHIP-AE domain scores. Results Missing answers were higher for father's (24.2%) and mother's (45.7%) occupational status than for parental education (8.4%, and 8.1% respectively), and belonging to a non-standard family was associated with more incomplete reporting of social position (OR = 4,98; 95%CI = 1,3–18,8) as was agreement between a parent and the adolescent. There were significant social class gradients, most notably for aspects of health related to resilience to threats to illness. Conclusion Adolescents can acceptably self-report on family occupation and level of education. Social class gradients are present in important aspects of health in adolescents.

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.

Background: Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings. Methods: Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected. Results: Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit. Conclusion: Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.