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Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically ( 88 ). This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

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.

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.

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.

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.

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.

Valid, comprehensive instruments to describe, monitor, and evaluate health from childhood through adolescence are almost nonexistent, but are critical for health resource planning, evaluation of policy, preventive, and clinical interventions, and understanding trajectories of health during this important period of life.The objectives of this study were to describe the development, testing, and final versions of the Parent Report Form of the Child Health and Illness Profile-Child Edition (CHIP-CE/PRF), designed to measure the health of children 6 to 11 years old from the caregiver perspective.Parents (N=1049) completed a version of the CHIP-CE/PRF in 4 locations in the United States, either in clinic waiting rooms or their homes. They differed in race/ethnicity, socioeconomic level, and native language.The Parent CHIP-CE is feasible; parents with a 5th-grade reading level complete the 76-item PRF in 20 minutes. Its domains (Satisfaction, Comfort, Risk Avoidance, Resilience, and Achievement) measure structurally distinct, interrelated aspects of health. Domain reliability is high: internal consistency=0.79-0.88; retest reliability (ICC)=0.71-0.85. Validity is supported. The scale scores are sensitive to predicted age, gender, and socioeconomic status differences in health.The CHIP-Child Edition/Parent Report Form is a psychometrically sound, conceptually based measure of child health that works well in diverse populations. It produces scores that parallel those of children on the CHIP-CE/CRF and adolescents on the CHIP-AE and allows health to be consistently assessed from childhood through adolescence. It should meet many needs for describing, monitoring, and understanding child health and evaluating outcomes of interventions.

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.

Objective.— To determine if there are social class gradients in health in children aged 6 to 11 years. Methods.— Self and parent reports of health of children in 5 sites across the United States were assessed using the Child Health and Illness Profile‐Child Edition. Distribution of scores in 4 domains: satisfaction (with health); comfort; resilience; and risk avoidance were used to create profiles of health. Social class was defined as a composite of parental education and work participation. Results.— Social class gradients were found for all but the satisfaction domain and for most subdomains in the parent version; the most notable gradient was in the risk avoidance domain, with better health the higher the social class. Apparent gradients did not reach statistical significance in the child reports. Children from a higher social class were more likely to be in excellent/average health and less likely to be in poor health profiles than were lower class children. Conclusions.— The findings generally mirror those from a prior study of adolescents, using the same conceptual framework for health and the same measure of social class, and are consistent with a cumulative effect for most aspects of health, and with a critical-period effect for risky behaviors. Ambulatory Pediatrics2002;2:238 246 A world-wide focus on achieving equity 1 and a US national focus on eliminating disparities in health by age, gender, race, ethnicity, social class, and disability 2 has focused attention on elucidating the reasons for inequities and disparities for the purpose of developing alternative strategies to deal with them. The earlier focus on poverty versus nonpoverty did not facilitate explanation of the mechanisms by which disparities arise; it is likely that the pathways to abject poverty are multiple and require multiple and simultaneously applied strategies. Recognition of the existence of social gradients, wherein health is better at each successively higher level of social position, has facilitated the development of hypotheses about the relative impact of a diverse set of adverse influences that manifest themselves in varying degrees along the social spectrum. 3,4 Understanding which pathways are most salient for which health outcomes would facilitate development of more informed health and social policies. The vast majority of studies on gradients have been conducted with adults; the literature has converged on the conclusion that the higher the social class, the lower the prevalence and severity of many, if not most, illnesses. The literature in children, and especially in early schoolage children, is much sparser and less conclusive. In an extensive recent review, Chen et al 5 concluded that there are social gradients in all-cause mortality, mortality from specific common chronic and acute conditions, parents’ ratings of their children’s health, injury rates, and mor

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.

Using the 1996 Community Tracking Study household survey, the authors examined whether income inequality and primary care, measured at the state level, predict individual morbidity as measured by self-rated health status, while adjusting for potentially confounding individual variables. Their results indicate that distributions of income and primary care within states are significantly associated with individuals' self-rated health; that there is a gradient effect of income inequality on self-rated health; and that individuals living in states with a higher ratio of primary care physician to population are more likely to report good health than those living in states with a lower such ratio. From a policy perspective, improvement in individuals' health is likely to require a multi-pronged approach that addresses individual socioeconomic determinants of health, social and economic policies that affect income distribution, and a strengthening of the primary care aspects of health services.

▪ Abstract The Balanced Budget Act of August 1997 was intended to improve the insurance coverage of low-income children. Although no specific mandates for evaluation accompanied the legislation, states are expected to assess its impact. Insurance improves access to and use of health services. The extent to which this is associated with better health depends on the kinds of services received. Access to a regular source of care is a critical characteristic. If this source of care provides good primary care, a variety of benefits would be expected to accrue. Thus, evaluation of the benefits of the State Children's Health Insurance Program should address not only improved coverage by health insurance for eligible children, but also the extent to which children receive high-quality primary care, including appropriate referrals when needed. Maternal access to and use of services is also a critical factor. Targets for evaluation include state activities to (a) enroll through outreach, inform through education, and develop information systems for tracking; (b) assess the degree of penetration of insurance among low-income children and their mothers, the availability of health care personnel, and the adequacy of benefits conferred by the insurance, primary-care services, and back-up specialty services; and (c) obtain evidence of improved health status. This article details approaches that can appropriately be used to address each of these aspects of concern.

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

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 an effort to provide medical care that is both more effective and less costly, the new variants of managed care organizations have instituted a variety of incentives and administrative controls that impact on the types and quantity of care provided to patients. Evidence suggests that the early forms of managed care, namely prepaid group practices, showed particular promise in improving the primary care delivered to children, ie, care that is accessible, person-focused in the long term, comprehensive, coordinated, and oriented toward achieving better outcomes. However, recent evidence concerning the quality of care delivered to children in the newer variants of managed care is mixed and scant; the newer organizational forms may not facilitate and may even have a negative impact on the attainment of primary care. Managed care can have a positive effect on first contact care, because it contractually defines a primary care provider and reduces use of the emergency room as a source of care. It may, however, have mixed effects on other aspects of access and use, depending on the plan's particular characteristics. Longitudinality is threatened by the disruption of prior relationships with out-of-plan providers and by the instability of both enrollees and providers in managed care plans. Children's benefits in managed care arrangements tend to include more preventive services, but access to specialty services has generally been found to be more restrictive. Coordination of care is not inherent to managed care, and many plans are no more likely to foster communication than are traditional indemnity plans. Evidence for the superior clinical quality afforded to children by new variants of managed care is lacking. Because managed care arrangements are proliferating rapidly, better studies are needed to prove or refute the contention that managed care has a significant positive effect on quality of care.

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.

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.

Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.

This discussion paper reflects on the pay-for-performance system in UK general practice - the Quality and Outcomes Framework (QOF) - from an international viewpoint. The QOF intends to bring the best scientific evidence to bear on primary care practice. However, the QOF and patient-centred medicine are often at odds. Inadequacies and commercial bias in the creation of evidence make the scientific basis of the QOF questionable. The framework for the QOF does not align well with the scope of primary care, making its basis as a tool for quality measurement questionable. The extent of impact of the QOF on health outcomes and on equity of health outcomes needs examination. Attention to resolution of patients' problems is an important aim of quality improvement activities. Alternative modes of improving patient care may be better than the QOF.

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.

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.

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.

The patient-centered medical home is evolving as an approach to providing primary care. Primary care is defined by four main characteristics: comprehensive, coordinated, continuous, and accessible care, all of which are measurable. This analysis identifies tools for determining whether a patient-centered medical home achieves high level primary care.Instruments for measuring primary care were reviewed.Tools were reviewed for population coverage, format, testing of validity and reliability, and inclusion of the attributes of primary care.Only one tool, the Primary Care Assessment Tool (PCAT), scored highly on primary care features, as it was designed to assess both structural and process features of primary care and is available in multiple user formats.Based on the evidence supporting the relationship between primary care, improved population health, and reduced health care costs, measurement of primary care transformation approaches such as the medical home can and should include specific measurement of the services associated with the four core attributes of primary care.

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.

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 …

Purpose. To examine the effects of patient, physician, and health care system characteristics on primary care physicians’ (PCPs’) specialty referral decision making. Methods. Physicians (n = 142) and their practices (n = 83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n = 34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. Results. Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gatekeeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. Conclusions. PCPs’ referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs’ thresholds for referring problems that could have been managed in their entirety within primary care settings.

Nearly 15 percent of children in the United States are inadequately insured because they lack health insurance for all or part of the year. In this issue of the Journal, Olson and colleagues1 describe the potent effect of inadequate insurance coverage on several aspects of access to services. They also examine several other effects of inadequate insurance coverage. Olson et al. characterized insurance coverage as full-year, part-year, or none and as private or public. The manifestations of compromised access to services were delays in seeking care, unmet medical care needs, unfilled prescriptions, no visits to doctors' offices, the lack of . . .

By conventional measures that focus on diseases, injuries, and mortality, children in the United States are healthier now than even a few decades ago. They are less likely to die in childhood and more likely to be protected by immunizations against serious infectious diseases. Rates of death from injuries and exposures to some environmental hazards have decreased. The infant mortality rate has declined from 26 per 1000 in 1960 to 7 per 1000 in 2003, while the mortality rate among those younger than 5 years has declined from 30 per 1000 to 8 per 1000 during these years. Should these facts be reassuring? Are correct measures being used to evaluate child health? If not, how should child health be assessed? Language: en

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 previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

This paper addresses the state of health of U.S. children and finds it to be poorer in virtually every way than that of children in other countries. It explores several possible explanations, including population heterogeneity, social (including income) inequality, and inadequacy of the health services system. The latter explanation is found to relate to the underdevelopment of U.S. primary care. In light of the position taken by the World Health Organization regarding the importance of primary care, adopting the recommendations of a new National Research Council/Institute of Medicine report and some changes in health policy could help improve the health of American children.

Objective. To review the extent to which the literature supports the position that a medical home is important and to review the extent to which insurance is related to having a medical home. Methods. A review of literature concerning the benefits of a medical home on effectiveness, costs, and equity (reducing disparities) was conducted. Results. International and within-nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations. Although important in facilitating use overall, insurance does not guarantee a medical home. Conclusions. A medical home, with its 4 key features, provides better effectiveness as well as more efficient and more equitable care to individuals and populations. A concerted attempt to provide a means of universal financial access as well as a medical home should be of high priority for the United States.

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA. Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled. Setting: Eleven years (1985–95) of data from 50 US states (final n = 549 because of one missing data point). Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p

Background: Valid, comprehensive instruments to describe, monitor, and evaluate health from childhood through adolescence are almost nonexistent, but are critical for health resource planning, evaluation of policy, preventive, and clinical interventions, and understanding trajectories of health during this important period of life. Objectives: The objectives of this study were to describe the development, testing, and final versions of the Parent Report Form of the Child Health and Illness Profile‐Child Edition (CHIP-CE/ PRF), designed to measure the health of children 6 to 11 years old from the caregiver perspective. Methods: Parents (N 1049) completed a version of the CHIPCE/PRF in 4 locations in the United States, either in clinic waiting rooms or their homes. They differed in race/ethnicity, socioeconomic level, and native language. Results: The Parent CHIP-CE is feasible; parents with a 5th-grade reading level complete the 76-item PRF in 20 minutes. Its domains (Satisfaction, Comfort, Risk Avoidance, Resilience, and Achievement) measure structurally distinct, interrelated aspects of health. Domain reliability is high: internal consistency 0.79 ‐ 0.88; retest reliability (ICC) 0.71‐ 0.85. Validity is supported. The scale scores are sensitive to predicted age, gender, and socioeconomic status differences in health. Conclusion: The CHIP‐Child Edition/Parent Report Form is a psychometrically sound, conceptually based measure of child health that works well in diverse populations. It produces scores that parallel those of children on the CHIP-CE/CRF and adolescents on the CHIP-AE and allows health to be consistently assessed from childhood through adolescence. It should meet many needs for describing, monitoring, and understanding child health and evaluating outcomes of interventions.

Rapidly occurring changes within the health care systems are creating an opportunity to re-orient the relationships between their different sectors. In order to know the locus of responsibility for various types of preventive activities, we undertook an inquiry on eight areas in six countries from Europe and North America.An inquiry among experts based on a matrix which arrayed the type of preventive health services against the target population. Eight clinical conditions were identified (childhood immunizations; adult influenza vaccination; mammography screening, tuberculosis screening, hypertension screening. PKU screening, HIV screening, and osteoporosis testing) trying to know their target population and the locus of responsibility for setting of policy, level to contact individuals for testing, follow-up of people with abnormal tests and maintenance of their medical records.This pilot study showed very little results coincidence either within the eight surveyed areas or across them. There was no regular pattern for the preventive activities studied among the different countries, neither according to the type of health system, nor to the primary health care orientation of the different systems.There was a limited consensus in the activities studied concerning the best mode of doing public health interventions for personal health services.

International health rankings for the US are heavily influenced by striking racial and socioeconomic health status disparities. Current discussions of health determinants frequently relegate or entirely dismiss health care contributions despite increasing evidence of the importance of access to primary care. Health centers deliver community-based primary care to a considerable and growing proportion of the nation's most vulnerable and have produced significant health improvements, especially for women and children. Policies that disproportionately benefit those in greatest need are likely to produce the largest gains in national health. Continued expansion of the health center network to ensure primary care for those who remain underserved is both an effective and politically acceptable strategy to improve national health.

This study used US state-level data from 1985 to 1995 to examine the relationship of primary care resources and income inequality with all-cause mortality within the entire population, and in black and white populations. The study is a pooled ecological design with repeated measures using 11 years of state-level data (n=549). Analyses controlled for socioeconomic and demographic characteristics. Contemporaneous and time-lagged covariates were modeled, and all analyses were stratified by race/ethnicity. In all models, primary care was associated with lower mortality. An increase of one primary care doctor per 10,000 population was associated with a reduction of 14.4 deaths per 100,000. The magnitude of primary care coefficients was higher for black mortality than for white mortality. Income inequality was not associated with mortality after controlling for state-level sociodemographic covariates. The study provides evidence that primary care resources are associated with population health and could aid in reducing socioeconomic disparities in health.

Summary Objective The objective of this study was to test whether the association between primary care and income inequality on all-cause, heart disease and cancer mortality at county level differs in urban (Metropolitan Statistical Area–MSA) compared with non-urban (non-MSA) areas. Study design The study consisted of a cross-sectional analysis of county-level data stratified by MSA and non-MSA areas in 1990. Dependent variables included age and sex-standardized (per 100,000) all-cause, heart disease and cancer mortality. Independent variables included primary care resources, income inequality, education levels, unemployment, racial/ethnic composition and income levels. Methods One-way analysis of variance and multivariate ordinary least squares regression were employed for each health outcome. Results Among non-MSA counties, those in the highest income inequality category experienced 11% higher all-cause mortality, 9% higher heart disease mortality, and 9% higher cancer mortality than counties in the lowest income inequality quartile, while controlling for other health determinants. Non-MSA counties with higher primary care experienced 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than non-MSA counties with lower primary care. MSA counties with median levels of income inequality experienced approximately 6% higher all-cause mortality, 7% higher heart disease mortality, and 7% higher cancer mortality than counties in the lowest income inequality quartile. MSA counties with low primary care (less than 75th percentile) had significantly lower levels of all-cause, heart disease and cancer mortality than those counties with high primary care. Conclusions In non-MSA counties, increasing primary physician supply could be one way to address the health needs of rural populations. In MSA counties, the association between primary care and health outcomes appears to be more complex and is likely to require intervention that focuses on multiple fronts.

This issue of the American Journal of Public Health contains 6 articles focusing on models of population health. These models are schematic representations of factors that affect the health of populations, measured primarily as the average level of health in the population, but increasingly also considering the distribution of health within populations. Taken together, these articles provide an introduction to current US, Canadian, and European debates over population health, the factors that influence population health, and the policy and programmatic implications of models of population health.

Numerous studies at both individual and ecological levels have established the salutary effect of primary care and shown its positive association with health outcomes (Starfield 1992, 1994, 1998; Institute of Medicine 1994; Shi 1992, 1994, 1995; Politzer et al. 1991; Bindman, Grumback, and Osmond 1996; Roos 1979; Greenfield, Rogers, and Mangotich 1995; Green 1996; Grumbach 1996; Donaldson and Vanselow 1996). Recent studies at both U.S. state and Primary Metropolitan Statistical Area have further demonstrated that primary care attenuates the adverse impact of income inequality on population health, as measured by life expectancy, age-adjusted mortality, and leading causes of death (Shi et al. 1999; Shi and Starfield 2000, 2001). The latter studies measured primary care as the number of primary-care specialty physicians who were in active office-based patient care per ten thousand civilian population, or primary-care physician-to-population ratio. The primary-care specialties included family practice and general practice, general internal medicine, and general pediatrics. While there is no doubt that these physician specialties in the United States are primarily engaged in primary care, this measure of primary care availability does not necessarily reflect the adequate practice of primary care and cannot distinguish differences in primary-care quality among primary-care physicians. The current study measures primary care by the achievement of its functions and examines the extent to which good primary-care experience attenuates the adverse association of income inequality with self-reported health. Our underlying assumption is that actual experiences with receipt of primary care are a better measure of the contribution of primary care than the simple presence of primary-care physicians. Using measures of primary-care experiences would provide a more definitive conclusion about whether and to what extent primary care moderates the adverse association of income inequality with health.