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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.

Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.

ObjectiveTo develop and validate a simplified, easy to interpret scoring system based on the health profile-types taxonomy for the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE).MethodsThe CHIP-AE was administered to a 1453 Spanish adolescents. Hierarchic and nonhierarchical cluster analyses, as well as conceptual considerations, were used to identify exhaustive, mutually exclusive health profile-types based in four CHIP-AE domain scores: Satisfaction, Discomfort, Resilience, and Risks. Validity of the health profile-types was assessed by testing expected differences among adolescents according to sex, age, socioeconomic status, and self-reported conditions. Logistic models were built.ResultsA total of 13 health profile-types (10 that best fitted the data and three additional considered conceptually necessary) were identified. The largest group of adolescents was in the “Excellent health” or “Good health” types (43.4%), although 11.2% were in the “Worst health” profile. According to a priori hypotheses, being a girl (OR = 1.81; 95% CI = 1.26–2.60), older age (OR = 1.80; 1.26–2.57), and self-reported recurrent (OR = 2.49; 1.72–3.60) and psychosocial disorders (OR = 4.38; 2.92–6.56) were associated to the likelihood of a “Worst health” profile-type.ConclusionsThe Spanish CHIP-AE health profile-types offer a simplified method to describe adolescents' patterns of health, which is valid and similar to the original US taxonomy. This can facilitate interpreting the instrument scores and using it for needs assessment, although additional research is required.

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005). In this issue of Health Services Research, Tom Ricketts and George Holmes published the results of analyses that refined previous analyses from the United States by examining the relationship between the supply of primary care physicians and age-adjusted total, heart disease, and cancer mortality at the county and regional level. Using pooled 1996–2000 U.S. county data, the authors found that the association between primary care physician supply and mortality varies across regions. A greater supply of primary care physicians is associated with decreased mortality on the east coast and in the upper midwest, but the correlation disappears or is reversed in the west (with the exception of Washington state) and south central states. The authors suggested that there are strong regional patterns that make national conclusions suspect. We applaud this excellent work on regional differences in primary care impact and agree that further study is needed to understand these regional differences and policy alternatives to address them. One hypothesis might be that an excessive supply and use of specialists might attenuate the effect of primary care in particular regions. Specialists are trained to do more testing than would be necessary in generalist practice, with consequent more false positive results, adverse effects from the resulting cascade of tests, and with much higher costs. Where the supply of specialists is excessive relative to that of primary care physicians, or where a large tertiary academic medical center is a dominant provider of care, the benefits of primary care physicians may not be achieved because primary care physicians may have a lower threshold for referral to specialists. Thus, the patterns of health outcomes and costs of care are likely to differ greatly across geographic areas with different generalist/specialist ratios and with the extent of dominance of hospital clinics on care, particularly of socially disadvantaged population groups. This may explain why studies such as those of Ricketts and Holmes (2007) show that the effect of the supply of primary care and specialty physicians on health outcomes varies from one region of the country to the other, but the dynamics of the relationship between the two types of physicians has not been explored. Ricketts and Holmes (2007) compared their analyses with those of our previous analysis using county-level data from the United States. However, there were major methodologic differences between the approaches. In our studies, the dependent variable, mortality, was not age adjusted due to the absence of age-adjusted mortality rates in the Area Resource File. Instead, to account for regional differences in age, we included a covariate, the percentage of the population 65 and older. Ricketts and Holmes (2007) computed age-adjusted mortality rates per 10,000 residents, using the Compressed Mortality Files from the National Center for Health Statistics, Centers for Disease Control and Prevention. However, they also included percentage of elderly in the same model, thus overadjusting for the effect of age. While examining the county-level data, we observed a large number of missing values for certain years for some counties. We used the “averaging” imputation method to “create” the values for these counties with missing values. In a few situations, severe outliers were also removed. Based on the methods described in Ricketts and Holmes's (2007) paper, apparently missing values were not specially treated and outliers were not removed. These analytic differences may explain the selected discrepancies in findings between our two studies. Other studies of the ecological association between primary care and population health have used various geographic levels, e.g., cross-nation, U.S. states, metropolitan statistical areas, and counties. Our experience with these analyses indicates that studies conducted at higher geographical units (e.g., cross-nation and U.S. states) tend to demonstrate more significant benefits of primary care than studies carried out at smaller geographical aggregations (e.g., metropolitan statistical areas and counties). We also believe it is more methodologically sound to conduct studies at higher geographical units. For example, through geographical aggregation at the state level, both numerators and denominators of the mortality and other rates are increased so that random fluctuations in these rates are less likely to confound findings. Further, using state-level aggregate data also has the advantage of attenuating the likely “crossover” effect that researchers encounter when smaller units of analysis (such as counties) are used when measuring availability of medical care and mortalities. The “crossover” effect refers to the likelihood that those who require medical care may be attracted to areas where that care is available and not necessarily where they live. Patients are less likely to travel between states than counties or cities to seek medical care. Nonetheless, there may be true differences across regions that are related to health system characteristics in different regions. Studies of the relationship between physician supply and health outcome cannot establish cause and effect. The absence of factors that intervene between workforce supply (a structural characteristic) and outcomes (health, disparities in health, or costs) is a major constraint in explaining the ecological associations. Mere presence of primary care clinicians does not assure availability and accessibility and does not guarantee that existing primary care facilities provide a level of primary care adequate to attain the four cardinal features of first contact use, person-focused care over time, comprehensiveness of services available and provided, and coordination of care. Dartmouth researchers have demonstrated great regional and local variation in quality of care, mostly with regard to hospitalization and surgery rates but also with the quality of hospital services (Skinner, Staiger, and Fisher 2006). The existence of similar regional variations in people's access to and use of primary care as a result of financing and/or organizational differences is highly likely, as are variations in professional practices in different regions, including hours of availability, comprehensiveness of services, referral patterns, and arrangements for coordination between hospital services and primary care practices. We know that past research, with individuals as the unit of analysis, shows strong relationships between people's primary care experiences and their reported and documented health (Starfield, Shi, and Macinko 2005, pp. 463–6). Regional variations in specialist availability and use are also likely to contribute to health outcomes, not always in positive ways (Starfield et al. 2005). The common wisdom that specialist care is always superior care, even for conditions in the province of the specialist, is contradicted by an increasing number of studies (Hartz and James 2006; Smetana et al. 2007). Thus, health services research faces a major and important challenge. Very little research attention has been devoted to health system organization at the macro level. Despite knowledge about the importance of primary care and the development of methods to measure primary care, very few researchers have recognized the importance of the nature of the source of care to responses to care. Even though the strength of people's relationships with primary care is known to be an important influence on health outcomes, a variable reflecting this characteristic has never been part of controlled clinical trials of interventions. Most studies of primary care come from primary care academicians and practitioners, not health services researchers. It is time to recognize that primary care and specialist care have different roles in delivering health services and to understand the impact of these differences on health outcomes and costs.

PURPOSE This study describes referral completion from the perspectives of patients and primary care physicians and identifies predictors of adherence to the referral recommendation. METHODS We observed a cohort of 776 referred patients from the offices of 133 physicians in 81 practices and 30 states. Referring physicians and patients completed self-administered questionnaires at the time of the referral decision and 3 months later. RESULTS Physicians reported that 79.2% of patients referred had a specialist visit, and 83.0% of patients indicated they completed the referral. The most common reasons for not completing the referral were “lack of time” and patient belief that the “health problem had resolved.” The κ statistic for patient-physician agreement on referral completion was 0.34, indicating only fair concordance. Patients in Medicaid plans were less likely than others to complete the referral, and more likely to experience a health plan denial. A longer duration of the patient relationship with the primary care physician and physician/staff scheduling of the specialty appointment were both positive predictors of referral completion. CONCLUSIONS About 8 in 10 patients referred from primary care complete a specialty referral within 3 months. Findings from this study suggest that referral completion rates may be increased by assisting patients with scheduling their specialty appointments and promoting continuity of care.

espite the availability of evidence on the benefits of primary care on population health, little has been done to incorporate this evidence into planning for and evaluation of health services in the United States. In contrast, many industrialized nations have undergone major health system reform to make primary care the essential infrastructure of their health system. Some of these reforms resulted from legislation, as was the case in Spain and Australia, and others have entailed policy decisions to strengthen the practice of good primary care, as has occurred in the United Kingdom (UK) and is now occurring in various aspects of primary care in Sweden, France, and Germany. The reasons the US has not embraced primary care are complex and get to the heart of the characteristics of the US health services system, particularly its increasing dominance by special interest groups such as the academic medical establishment and specialty orientation, medical device manufacturers, and fee-for-service reimbursements that favor specialty practice. 1 In this paper we briefly review the evidence for the impact of primary care in improving health, increasing equity, and reducing total health system costs; discuss the rationale for benefits of a primary care orientation within health services systems; and conclude with a discussion of needed additional research and policy attention. Benefits of Primary Care The first systematic study of the benefits of primary care on health and costs of care consisted of an international comparison of 11 western industrialized nations using data from the mid-1980s. 2 The study was repeated a decade later with 13 countries including Japan. 3 Both studies rated countries on policy characteristics encouraging primary care and practice characteristics reflecting primary care organization: first contact care; person-focused care over time; degree of comprehensiveness within primary care; and coordination of care. The studies were consistent in showing that some countries rated very poorly on primary care whereas others rated better. Those in the former group had poorer health on many population health measures including but not limited to life expectancy at various ages, age-adjusted mortality, and infant mortality (neonatal and postneonatal separately). They also were more costly health systems. These findings were robust and persisted even after controlling for various health-related characteristics of the population (such as extent of risky behaviors in the population). Confidence in the findings was provided by a pooled time series analysis of 18 Organization for Economic Co-operation and Development (OECD) countries that controlled for additional health and health system-related characteristics (such as percent

An increasing number of studies are documenting the existence of inequities, and attention is now turning to exploring pathways through which they are generated and might be attacked. This appears to be an opportune time to consider what has been learned and what future directions might be taken by researchers to fill gaps in knowledge and make research more useful for policy interventions. This commentary briefly reviews some of the main contributions of past research that have possible relevance to pathways, considers what those pathways might include, and concludes with implications for future research. It makes the case for a conceptualization of influences on equity that explicitly includes distribution of health as an outcome as well as characteristics of the society as influences.

This analysis addresses the question, Would increasing the number of primary care physicians improve health outcomes in the United States? A search of the PubMed database for articles containing “primary care physician supply” or “primary care supply” in the title, published between 1985 and 2005, identified 17 studies, and 10 met all inclusion criteria. Results were reanalyzed to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. This relationship held regardless of the year (1980–1995) or level of analysis (state, county, metropolitan statistical area (MSA), and non-MSA levels). Pooled results for all-cause mortality suggest that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year.

Background: The aim of the present study was to analyse the use of healthcare services according to health status in a population of children and adolescents, taking into account family socio-demographic characteristics and characteristics of the proxy respondent. Methods: A total of 836 interviews of proxy respondents for children aged 5–14 years from the Barcelona Health Interview Survey carried out in 2000 were included. Dependent variables were visits to a healthcare professional, visits to the emergency room, and hospitalization. Independent variables were: report of medical conditions, health status of the child measured by the Child Health and Illness Profile-Child Edition, Parent Report Form (CHIP-CE/PRF), the educational level of the head of household, social class, child's healthcare coverage, and proxy-related variables [mental health status by means of the General Health Questionnaire-12 items version (GHQ-12), and other]. Logistic regression analysis was used to estimate prevalence ratio (PR) to compare the use of healthcare services among different categories of independent variables. Results: Children having worse health status were more likely to have visited a healthcare professional [PR = 1.68; 95% confidence interval (95% CI) = 1.09–3.83], whereas children with a reported medical condition were more likely to have made a visit to the emergency service (PR = 1.47; 95% CI = 1.27–2.55) and were hospitalized more frequently (PR = 2.50; 95% CI = 1.12–5.57). Higher likelihood of visits to the emergency room was associated with children having both public and private coverage and a proxy respondent scoring 3 or higher on the GHQ-12. Conclusions: Use of healthcare services differed by health needs but not by social class. Double healthcare coverage and mental distress of the proxy respondent influenced the use of emergency services.

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Funding for clinical research has changed dramatically over the past 2 or 3 decades. Before 1970, few clinical studies were sponsored solely by the drug companies.[1][1] A 1982 article in the journal Science noted the transition: “Scientists who 10 years ago would have snubbed their academic noses

PURPOSE The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid conditions, and use of primary care and specialist services METHODS The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare files. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one first considered as the “main” one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system. RESULTS Higher morbidity burden was associated with more visits to specialists, but not to primary care physicians. Patients with most diagnoses had more visits, both to primary care and specialist physicians for comorbid diagnoses than for the main diagnosis itself. Although patients, especially those with high morbidity burdens, generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups; for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups. CONCLUSION In the elderly, a high morbidity burden leads to higher use of specialist physicians, but not primary care physicians, even for patients with common diagnoses not generally considered to require specialist care. This finding calls for a better understanding of the relative roles of generalists and specialists in the US health services system.

Objectives. We tested the association between the availability of primary care and income inequality on several categories of mortality in US counties. Methods. We used cross-sectional analysis of data from counties (n=3081) in 1990, including analysis of variance and multivariate ordinary least squares regression. Independent variables included primary care resources, income inequality, and sociodemographics. Results. Counties with higher availability of primary care resources experienced between 2% and 3% lower mortality than counties with less primary care. Counties with high income inequality experienced between 11% and 13% higher mortality than counties with less inequality. Conclusions. Primary care resources may partially moderate the effects of income inequality on health outcomes at the county level.

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previ...

ObjectiveTo compare the characteristics of patients, their disease patterns, and the investigation and referral patterns in private community-governed not-for-profit and private for-profit primary care practices in New Zealand.MethodsObservational study using a representative survey of visits to general practitioners in New Zealand. Practices were categorised according to their ownership: private for-profit or private community-governed not-for-profit. Patient socio-demographic characteristics, treated prevalence and other characteristics of presenting problems, morbidity burden, numbers of investigations and referral patterns were compared.ResultsCompared with for-profit practices, community-governed not-for-profit practices served a younger, largely non-European population, nearly three-quarters of whom had a means-tested benefit card (community services card), 10.5% of whom were not fluent in English, and the majority of whom lived in the 20% of areas ranked as the most deprived (by the NZDep2001 index of socio-economic deprivation). Patients visiting not-for-profit practices were diagnosed with more problems, including higher rates of asthma, diabetes and skin infections, but lower rates of chest infections. The duration of visits was also significantly longer. No differences were observed in the average number of laboratory tests ordered. The odds of specialist referral were higher in for-profit patients when confounding variables were controlled for.ConclusionsCommunity-governed not-for-profit practices in New Zealand serve a poor, largely non-European population who present with somewhat different rates of various problems compared with patients at for-profit practices. The study highlights for communities, policy-makers and purchasers the importance of community-governed not-for-profit practices in meeting the needs of low-income and minority population groups.

Developing strategies to reduce inequities in health requires an understanding of how inequities occur, determining the salient factors in their production, and deciding which ones are most amenable to change. The recognition of several principles regarding the manifestations and genesis of inequities can help to decide on strategies. In making decisions, it is important to consider whether the aim is to reduce disparities in the occurrence of ill health or to reduce disparities in the severity (including co-morbidity, disability, dysfunction and fatality) of ill health. Evidence shows that the major impact on equity of health services, particularly regarding their potential to reduce severity, is attributable to the strength of primary care resources and services in communities and countries. Virtually every influence on the genesis of inequities is determined by the political context in which policy is made. The issue of health services is not different in this regard from other types of strategies. There is no longer any doubt about the pervasive influence of social factors on health. Almost two centuries of descriptive research provides convincing evidence of associations between social structures and relationships and health status in all countries and in all societies; if there is anything new from more recent research, it is that the association is not limited to differences between the lowest social strata and other social strata. Rather, the association is noted throughout the social spectrum. That is, there is a social gradient in health such that, for many if not most manifestations of ill health, the lower the social stratum, the worse the health. The challenge for the future is to understand why this is the case, to create a consensus that these inequalities are unnecessary and unacceptable, and to devise strategies that are both effective and possible. This paper will focus on the first of these aims, in a context that facilitates attention to the second and third aims.

Objective: The objective of this study was to examine the relationship between healthcare use and children’s healthcare needs as assessed from the perspectives of children themselves, parents, and healthcare practitioners. Research Design: We conducted a prospective cohort study in which service use was monitored for the 12 months before and after administration of a health survey. Subjects: We studied 384 parents and children aged 6 to 11 years enrolled for 2 years in a northern California health maintenance organization or a Medicaid managed care program in Rhode Island. Measures: Child and parent perspectives on needs were determined using the Child Health and Illness Profile, Child Edition (CHIP-CE). Plan administrative data were used to develop a treated morbidity index, which was based on diagnosis codes recorded by practitioners during the year before the survey and to obtain prospective measures of service use. Results: For both child- and parent-respondents, low satisfaction and comfort scale scores from the CHIP-CE were significant predictors of number of visits. CHIP-CE domain scales unrelated to future use were risk avoidance, resilience, and achievement. Multivariable regression using CHIP-CE information collected from children explained more variation in total physician visits than models that used parent-respondent data. The treated morbidity index was a weaker predictor of physician visits than the CHIP-CE scale scores. None of the domain scales were significant predictors of any emergency department use or any specialist use; however, the treated morbidity index was associated with any specialist use. Conclusions: A child’s sense of well-being and burden of symptoms predict future use. Perceived healthcare needs, as assessed by the CHIP-CE, is a better predictor of children’s service use than evaluated needs as assessed by physician-diagnosed disorders. Our results support the validity of using the responses of children aged 6 to 11 years as a measure of need for future health care.

This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.

Background and Purpose— The goal of this study was to test whether primary care reduces the impact of income inequality on stroke mortality. Methods— This study used pooled time-series cross-sectional analysis of 11 years of state-level data (n=549). Analyses controlled for education levels, unemployment, racial/ethnic composition, and percent urban. Contemporaneous and time-lagged covariates were modeled. Results— Primary care was negatively associated with stroke mortality in models including all covariates ( P P P >0.05). Conclusions— In the absence of social policy that addresses sociodemographic determinants of health, primary care promotion may serve as a palliative strategy for combating stroke mortality and reducing the adverse impact of income inequality on health.

BACKGROUND Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients’ overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

The aim of the study was to obtain a conceptually equivalent Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE TM ), and to test its feasibility, reliability and preliminary construct validity. The methodology used for adaptation was forward-back translation, including two focus groups with adolescents and a panel of experts. Reliability and validity were assessed in healthy convenience samples from school settings (n ¼ 417). Three different illness groups (n ¼ 67) were used to examine differences in health status between healthy, acutely ill, chronically ill and mentally ill adolescents. Preliminary construct validity was examined by comparing mean scores for each of the subdomains to determine if they differed in predicted ways according to age, gender and illness group. The majority of items (154 out of 203) were conceptually equivalent to the original version. Some items (46) had to be modified to increase clarity and/or to adapt them for use in Spain and 3 items were considered not applicable. Single construct subdomains achieved a coefficients between 0.65 and 0.92, and intraclass correlation coefficients (ICC) between 0.57 and 0.93. The mentally ill group presented the worst scores in most domains. The Spanish CHIP-AE is acceptable for Spanish adolescents and shows adequate metric characteristics, which are similar to those reported in the US version.

The demand for services for predicting, diagnosing, and managing genetic diseases or diseases with a genetic component is likely to increase faster than the availability of services from medical geneticists and genetic counselors. Health care systems may also impose limitations on referrals to these specialists. If genetic problems are not to be missed and excessive referrals are to be avoided, non-geneticist practitioners will have to recognize when genetic problems should be considered, and initiate diagnosis and even management. Primary-care-centred systems offer the greatest potential for maximizing overall cost-effectiveness, by reducing the demand for specialty services not essential for improving health. But primary-care-centred systems may pose a risk of underdetection and undermanagement of genetic problems if practitioners are not actively supported by information and other educational networks. Several models for dealing with these challenges are presented, including algorithms that aid in recognizing genetic problems.

Objectives.—To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians. Methods.—We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes. Results.—Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups. Conclusions.—Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.

Objectives. This study assessed whether income inequality and primary care physician supply have a different effect on mortality among Blacks compared with Whites. Methods. We conducted a multivariate ecologic analysis of 1990 data from 273 US metropolitan areas. Results. Both income inequality and primary care physician supply were significantly associated with White mortality (P < .01). After the inclusion of the socioeconomic status covariates, the effect of income inequality on Black mortality remained significant (P < .01), but the effect of primary care physician supply was no longer significant (P > .10), particularly in areas with high income inequality. Conclusions. Improvement in population health requires addressing socioeconomic determinants of health, including income inequality and primary care availability and access.

Celia Almeida MDa, Paula Braveman MDc, Marthe R Gold MDd, Celia L Szwarcwald DrPhb, Jose Mendes Ribeiro MDa, Americo Miglionico MSe, John S Millar MDf, Silvia Porto PhDa, Nilson do Rosario Costa PhDa, Vincente Ortun Rubio PhDg, Malcolm Segall MRCPh, Barbara Starfield MDi, Claudia Travessos MDb, Alicia Uga PhDa, Joaquim Valente MDa and DrFrancisco Viacava MDb/ a National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/ b Health Information Department, Center for Scientific and Technological Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/c Department of Family and Community Medicine, University of California, San Francisco, USA/d Department of Community Health and Social Medicine, City University of New York Medical School, New York, USA/e Consultant to Ministry of Health, Montevideo, Uruguay/ f Canadian Institute for Health Information, Ottawa, Canada/ g Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain/h Health Unit, Institute of Development Studies, Sussex, UK/ i Johns Hopkins Medical Institutions, Baltimore, USA

There are no standard methods for assessing the quality of young children's perceptions of their health and well-being and their ability to comprehend the tasks involved in reporting their health. This research involved three cross-sectional studies using cognitive interviews of 5-11-year-old children (N = 114) to determine their ability to respond to various presentations of pictorially illustrated questions about their health. The samples had a predominance of children in the 5-7-year-old range and families of lower and middle socio-economic status. The research questions in Study 1 involved children's ability to convert their health experiences into scaled responses and relate them to illustrated items (n = 35); Study 2 focused on the type of response format most effectively used by children (n = 19); and Study 3 involved testing children's understanding of health-related terms and use of a specific recall period (n = 60). The results of Study 1 showed that children identified with the cartoon drawing of a child depicted in the illustrated items, typically responding that the child was at or near their own age and of the same gender, with no differences related to race. Study 2 results indicated that children responded effectively to circles of graduated sizes to indicate their response and preferred them to same-size circles or a visual analogue scale. Tests of three-, four-, and five-point response formats demonstrated that children could use them all without confusion. In Study 3, expected age-related differences in understanding were obtained. In fact, the 5-year-old children were unable to understand a sufficient number of items to adequately describe their health. Virtually all children 8 years of age and older were able to fully understand the key terms and presentation of items, used the full five-point range of response options, and accurately used a 4-week recall period. Six- and seven-year-olds were more likely than older children to use only the extreme and middle responses on a five-point scale. No pattern of gender differences in understanding or in use of response options was found. We conclude that children as young as eight are able to report on all aspects of their health experiences and can use a five-point response format. Children aged 6-7 had difficulty with some health-related terms and tended to use extreme responses, but they understood the basic task requirements and were able to report on their health experiences. These results provide the guidance needed to develop and test a pediatric health status questionnaire for children 6-11 years old.

Aims—To analyse inequalities by social class in children’s access to and utilisation of health services in Catalonia (Spain),private health insurance coverage,and certain aspects of the quality of care received. Design—Cross sectional study using data from the 1994 Catalan Health Interview Survey. Setting—Child population of Catalonia. Participants—A representative sample of non-institutionalised children younger than 15 years (n = 2433). Main outcome measures—Health services utilisation, perceived health, type of health insurance (only National Health System (NHS) or both NHS and private health insurance), and social class. Results—No inequalities by social class were found for the utilisation of health care services provided by the NHS among children in most need. Double health care coverage does not influence the social pattern of visits. Nevertheless, social inequalities still remain in the use of those health services provided only partially by the NHS (dentist) and when characteristics of the last consultation are taken into account. That is, subjects who paid for a private service waited an average of 14.8 minutes less than those whose visit was paid for by the NHS only. Conclusion—Equitable access and use of medical care services in relation to need, regardless of the type of insurance and social class of their children and families, has been achieved in this region of Spain; diVerences by social class remain for those services incompletely covered by national health insurance and aspects of the quality of care provided. (Arch Dis Child 2000;83:211‐214)

Background: Although numerous changes are apparent in the US health care system, little is known about how these changes have altered the work of primary care physicians. Methods: We analyzed a nationally representative sample of 136 233 adult office visits to general internists, general practitioners, and family physicians contained in the 1978 through 1981, 1985, and 1989 through 1994 National Ambulatory Medical Care Surveys. Annual sample sizes varied between 5662 and 19 977 visits. Measures included the characteristics of patients presenting to primary care physicians, physician activities during these visits, and the disposition of the visits to primary care physicians. Results: Visits to primary care physicians have diminished as a proportion of all adult visits from 52% in 1978 to 41% in 1994. Dramatic trends in adult primary care included the growing racial or ethnic diversity of patients, the doubling (since 1985) of health maintenance organization coverage, increased provision of prevention services, changes in the most common medications, and an 18% increase in the duration of adult visits to primary care physicians. Conclusions: Trends in primary care practice reflect changes in society and in the US health care system, including demographic changes, an emphasis on prevention, and the growth of managed care. The increasing role of managed care, with its emphasis on increased productivity, appears at odds with primary care physicians’ increasing responsibility for prevention and the associated increase in the duration of primary care visits. Arch Fam Med. 1999;8:26-32

Global health provides a special challenge for primary care and general practice, which will become increasingly important in the future as the prevalence of multimorbidity increases with increasing likelihood of survival from acute manifestations of illness, as populations age, and as costs of care increase with increasing availability of technologic interventions. World organizations of primary care physicians need to take up the challenge before it becomes a crisis.

The purpose of this study was to demonstrate the preliminary reliability and validity of a set 13 profiles of adolescent health that describe distinct patterns of health and health service requirements on four domains of health.Reliability and validity were tested in four ethnically diverse population samples of urban and rural youths aged 11 to 17-years-old in public schools (N = 4,066). The reliability of the classification procedure and construct validity were examined in terms of the predicted and actual distributions of age, gender, race, socioeconomic status, and family type. School achievement, medical conditions, and the proportion of youths with a psychiatric disorder also were examined as tests of construct validity.The classification method was shown to produce consistent results across the four populations in terms of proportions of youths assigned with specific sociodemographic characteristics. Variations in health described by specific profiles showed expected relations to sociodemographic characteristics, family structure, school achievement, medical disorders, and psychiatric disorders.This taxonomy of health profile-types appears to effectively describe a set of patterns that characterize adolescent health. The profile-types provide a unique and practical method for identifying subgroups having distinct needs for health services, with potential utility for health policy and planning. Such integrative reporting methods are critical for more effective utilization of health status instruments in health resource planning and policy development.

As well as learning from each other's existing systems, US and UK researchers have potential for collaborative research into improving health care Almost a century ago, the UK and US health systems diverged in a dramatic way. In the United Kingdom, parliament legislated on health insurance; subsequent seminal governmental reports and actions, such as the Dawson report on primary care after the first world war and the enactment of the NHS, set the stage for the current health services system. Despite several notable attempts at reform in the United States, particularly in the early 1930s, mid-1960s, and early 1990s, the US healthcare system remains much like it was a century ago, mired in a market oriented private system with private financing. The system makes only a nod towards public responsibility, mainly in the form of guaranteed financial access for elderly people (Medicare) and a fragmented and unstable system of financing and direct service for care of poor people (Medicaid and community health centres, respectively). As a result, the United States lacks system-wide health policy making. By contrast, the NHS assumes responsibility for national health policy, the quality of care (for example, the National Institute for Clinical Excellence), and banning direct to consumer advertising of prescription medicines. The United Kingdom has a national director for primary care who, besides being responsible for policy in various aspects of primary care, is the country's official representative in international deliberations on primary care. The United States has no comparable position. Despite these enormous differences between the two health systems, there remain possibilities for two-way learning. These fall into several groups: the importance of primary care as the infrastructure of a health system; information technologies for health services; quality of services; and equity in the attainment of health of populations. World Health Organization documents on …

In the United States, hospital admissions for conditions sensitive to primary care are related to socioeconomic characteristics. The authors compare the prevalence of avoidable hospital admissions and their relationship to socioeconomic and primary care characteristics in Spain and the United States. A case-control analysis of the relationship between avoidable hospitalizations and socioeconomic characteristics (illiteracy, unemployment, income) and primary care characteristics (type of physician and facilities for primary care) of children's area of residence was conducted in Spain. Bivariate statistical tests and conditional logistic regression were used to test the strength of the association among the variables, and to calculate the probability of being admitted to hospital for treatment of an ambulatory care sensitive (ACS) condition. Neither socioeconomic nor primary care characteristics affected this probability, and the rate of admission for ACS conditions was lower in Spain than in the United States. The provision of universal financial access to care and the availability of a consistent and accountable primary care provider are associated with lower hospitalization rates for conditions that are preventable with good primary care.

The concept—and reality—of continuity of care crosses disciplinary and organisational boundaries. The common definitions provided here should help healthcare providers evaluate continuity more rigorously and improve communication Patients are increasingly seen by an array of providers in a wide variety of organisations and places, raising concerns about fragmentation of care. Policy reports and charters worldwide urge a concerted effort to enhance continuity,1–3 but efforts to describe the problem or formulate solutions are complicated by the lack of consensus on the definition of continuity. To add to the confusion, other terms such as continuum of care, coordination of care, discharge planning, case management, integration of services, and seamless care are often used synonymously. This synthesis was commissioned by three Canadian health services policy and research bodies. The aim was to develop a common understanding of the concept of continuity as a basis for valid and reliable measurement of practice in different settings. We searched academic and policy literature for documents in which the principal focus was continuity of patient care or continuity. We searched electronic databases (Medline, HealthSTAR, Embase, CINAHL, Current Contents, PsychINFO, AIDSLINE, CancerLit, Cochrane Library, Dissertation abstracts, Papers1st (conferences and paper abstracts), Web of Science, WorldCat) as well as web library catalogues, peer reviewed internet sites, internet search engines, and several in-house databases. The search included documents dated from 1966 to November 2001 written in English, French, or Spanish. The reviewers (RJR, JLH, RMcK) used a data abstraction form to summarise relevant documents from every health discipline, and all reviewers read key documents. We presented the results of an initial review of 314 documents to participants of a workshop on continuity held in Vancouver in June 2001. We obtained structured feedback to a discussion paper, problem based scenarios, and expert presentations. Participants validated the common themes …

Background There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. Objective Assessing the primary care development in Austria. Methods A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). Results Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. Conclusion This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.

Because improving health is the ultimate goal of a health care system, the measurement of health outcomes in research is a logical and important goal for the evaluation of the impact of health services. Although health can be defined in various ways, here we employ a conceptualization that has several domains including longevity, disease, comfort, perceived well being, activity, achievement, and resilience. Given that health is such a broad concept, the difficult task for outcomes research is to provide the means of measuring it. As this brief summary of current work indicates, a number of approaches have been used in recent pediatric studies. Most focus on a small subset of health concerns. However, some studies have attempted to broaden the assessment of health outcome either by using multiple health measures or developing multidimensional instruments for measuring health. Care must be taken in evaluating the usefulness of any of the instruments until sufficient data are obtained as to their reliability and validity. Further work in this area is needed, particularly with regards to multidimensional approaches, which are beginning to provide a more sensitive and comprehensive means of assessing the impact of health services.

Both patient-centered and person-focused care are important, but they are different. In contrast to patient-centered care (at least as described in the current literature with assessments that are visit-based), person-focused care is based on accumulated knowledge of people, which provides the basis for better recognition of health problems and needs over time and facilitates appropriate care for these needs in the context of other needs. That is, it specifically focuses on the whole person. Proposed enhancements and innovations to primary care do not appear to address person-focused care. Tools to assess person-focused care are available and deserve more widespread use in primary care.

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 Primary Care Assessment Tool (PCAT) is an interesting set of tools for primary care research. A very short version could inform policy makers about consumer experiences with primary care (PC) through health surveys. This work aimed to investigate the validity and reliability of a selection of items from the child short edition (CS) of the PCAT. Methods A 24 item questionnaire permitted the identification of a regular source of care and the assessment of the key attributes of first contact, ongoing care over time, coordination, services available and services received (comprehensiveness), and cultural competence. Structural validity, reliability, and construct validity were assessed using responses from 2,200 parents of a representative sample of the population aged 0 to 14 years in Catalonia (Spain) who participated in the 2006 Health Survey. Structural validity was analyzed using exploratory and confirmatory factor analyses and reliability was assessed using Cronbach's alpha. Construct validity was assessed using linear regression analysis between PC experience scores and a measure of overall user satisfaction with healthcare services. Results A total of 2,095 (95.2%) parents provided useable responses on PC. After Confirmatory Factor Analysis (CFA), the best fitting model was a 5-factor model in which the original dimensions of first contact and ongoing care were collapsed into one. The CFA also showed a second order factor onto which all domains except services available loaded (root mean square error of approximation = 0.000; comparative fit index = 1.00). Cronbach's alpha values for one of the original scales (first-contact) was poor (alpha < 0.50), but improved using the modified factor structure (alpha > 0.70). Scores on the scales were correlated with satisfaction with healthcare services (p < 0.01), thereby providing some preliminary evidence of construct validity. Conclusions This very short questionnaire obtained from the PCAT-CE yields information about five attributes of PC and a summary score. It has shown evidence of validity and reliability for judgments about experiences with primary care overall. If space on surveys is at a premium, the instrument could be useful as a measure of PC experiences.

Factors related to the amount of health care used by 5- to 11-year-old children in a health maintenance organization (HMO) were investigated using a comprehensive multivariate model that assessed the contribution of child health need, mental health, and social functioning; maternal mental health, social support and health care utilization; and family functioning and life events. Mothers reported on the 450 participating children. Health care visits for a two-year retrospective period were obtained from the computerized encounter system. Child health need and maternal patterns of health care use were powerful predictors of the overall amount of health care used, and these factors discriminated high users from low users of care. Family conflict was associated with a higher volume of care, while children's depressive symptoms and non-white race were related to lower use. Maternal social support, mental health, and life events were not predictive of use in either full multivariate model. Enabling factors were held relatively constant by participation of all families in a prepaid HMO. The multiple regression model explained 33% of the variance in use, slightly more than in previous studies of children's health care use. When included in a comprehensive analysis, child and family psychosocial characteristics help to explain children's health care use beyond what is possible using simple health and illness variables. The implications of these findings in the development of further research and to the practice of routine pediatric care are discussed.

Both poverty and other factors associated with race are related to child health. However, the mechanisms of these relationships have not been adequately specified. The purpose of this study was to explore the relationship of the social environment to child health status in black and white children and further, to explore whether the patterns of the effects of social class were different by race. This study provides further evidence that the social environment is strongly associated with child health status. Several risk factors are similar for both white and black children: mothers who view their own health as fair or poor are much more likely to rate their children in poor health. The presence of childhood chronic medical conditions is independently associated with poor health status regardless of race. However, the relative importance of several social risks for poor health status differs between white and black children. Specifically, while low family income is a consistent risk factor for poor health among white children, low income alone is not a risk factor for black children. Among black children,other social risks that are associated with poverty, such as low maternal education and a mother's perception of her own health as poor, increased the risk for poorer health in the child.

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.

Canada is, in many respects, culturally and economically similar to the United States, and until relatively recently, the two countries had similar health systems. However, since passage of the Canada Health Act in the 1970s, that nation's health statistics have become increasingly superior. Although the costs of Canada's health system are high by international standards, they are much lower than U.S. costs. This paper describes several factors likely to be responsible for Canada's better health at lower cost: universal financial coverage through a so-called single payer; features conducive to a strong primary care infrastructure; and provincial autonomy under general principles set by national law.

Approximately 7 of 10 (and 95% of the elderly) people in US health plans see one or more specialists in a year. Controlling for extent of morbidity, discontinuity of primary care physician visits is associated with seeing more different specialists. Having a general internist as the primary care physician is associated with more different specialists seen. Controlling for differences in the degree of morbidity, receiving care from multiple specialists is associated with higher costs, more procedures, and more medications, independent of the number of visits and age of the patient.

This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice. The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.

Expectations are high for the Obama presidency. People worked hard on his campaign, more because of his perceived integrity than his platforms (which were not well defined). Is it realistic to expect Obama to make a real difference? The primary health policy focus of the presidential campaign was on achieving universal coverage with health insurance. It is an international scandal that the USA has between 50 and 100 million people (between 15% and 30% of its population) without adequate coverage for their healthcare costs—the leading cause of bankruptcy in the country and a postulated major cause of excess deaths among the socially deprived. In the Democratic presidential primaries, there were only relatively minor differences having to do with methods of financing and whether obtaining insurance would be mandatory. No one asked whether universal insurance would measurably improve population health statistics or disparities in health (the US ranking has fallen to between 20th and 30th in the world on major health indicators, with increasing inequities). Since his election, the nomination of Tom Daschle for the cabinet position of Secretary of Health and Human Services signals what “reforms” might be sought. Daschle’s recent book1 is noteworthy in its precise and detailed history of …