Search

Over time, the definition of prevention has expanded so that its meaning in the context of health services is now unclear. As risk factors are increasingly considered to be the equivalent of ‘‘diseases’’ for purposes of intervention, the concept of prevention has lost all practical meaning. This paper reviews the inconsistencies in its utility, and suggests principles that it should follow in the future: a population orientation with explicit consideration of attributable risk, the setting of priorities based on reduction in illness and avoidance of adverse effects, and the imperative to reduce inequities in health.

Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.

Income inequality is widely assumed to be a major contributor to poorer health at national and subnational levels. According to this assumption, the most appropriate policy strategy to improve equity in health is income redistribution. This paper considers reasons why tackling income inequality alone could be an inadequate approach to reducing differences in health across social classes and other population subgroups, and makes the case that universal social programs are critical to reducing inequities in health. A health system oriented around a strong primary care base is an example of such a strategy.

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

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

Estratégias em saúde baseadas na atenção primária à saúde vêm aumentando no Brasil. Existe um instrumento aplicado a usuários, o Primary Care Assessment Tool (PCATool), que mede a extensão dos atributos da atenção primária à saúde, já validado nos Estados Unidos. Objetivamos adaptar o PCATool ao Brasil e analisar sua validade e confiabilidade, por meio de estudo seccional de validação da sua versão infantil. A validação constou de: tradução e tradução reversa, adaptação, pré-teste, validade de construto, consistência interna e análise de confiabilidade. O questionário foi aplicado a 468 cuidadores de crianças cadastradas em 18 serviços de atenção básica de Porto Alegre, Rio Grande do Sul, Brasil, representativos deste universo de usuários. Na análise fatorial foram identificadas oito dimensões, com o α de Cronbach variando de 0,74 a 0,88. O instrumento final ficou com 45 itens, divididos em oito atributos (acesso de primeiro contato, continuidade, coordenação, três atributos de integralidade, orientação familiar e comunitária). Estes resultados indicaram que o PCATool-Brasil possui adequada validade e confiabilidade, podendo constituir-se em instrumento nacional de avaliação da atenção primária à saúde após sua aplicação em outros contextos populacionais. Health strategies based on primary health care have been expanding in Brazil. An instrument applied to users, the Primary Care Assessment Tool (the PCATool), which measures the extent of primary care, has been validated in the United States. We sought to adapt the PCATool to Brazil and analyze its validation and reliability through a cross-sectional validation study of the Child PCATool.Validation included: translation, back-translation, adaptation, debriefing, content and construct validate, internal consistency, and reliability analysis. The questionnaire was applied to 468 parents or guardians of children registered with 18 primary health services in Porto Alegre, representing the services’ normal pediatric population. Using factor analysis, 8 domains were identified, with Cronbach’s α ranging from 0.74 to 0.88.Validation resulted in a 45-item scale, divided into 8 attributes (Access to First Contact, Continuity, Coordination, 3 attributes of Comprehensiveness, Community Orientation, and Family Orientation). These results showed that the PCATool-Brasil has adequate validity and reliability and could be used as a national instrument to evaluate primary health care after its application to other population settings in the country. Telemedicina

Health strategies based on primary health care have been expanding in Brazil. An instrument applied to users, the Primary Care Assessment Tool (the PCATool), which measures the extent of primary care, has been validated in the United States. We sought to adapt the PCATool to Brazil and analyze its validation and reliability through a cross-sectional validation study of the Child PCATool. Validation included: translation, back-translation, adaptation, debriefing, content and construct validate, internal consistency, and reliability analysis. The questionnaire was applied to 468 parents or guardians of children registered with 18 primary health services in Porto Alegre, representing the services' normal pediatric population. Using factor analysis, 8 domains were identified, with Cronbach's aranging from 0.74 to 0.88. Validation resulted in a 45-item scale, divided into 8 attributes (Access to First Contact, Continuity, Coordination, 3 attributes of Comprehensiveness, Community Orientation, and Family Orientation). These results showed that the PCATool-Brasil has adequate validity and reliability and could be used as a national instrument to evaluate primary health care after its application to other population settings in the country.

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.

This essay provided the introduction to a workshop in Bellagio, Italy, on the subject of translating research into policy for equity in health. The essay first defines equity in a way that facilitates its assessment and monitoring and then sum - marizes evidence from existing research. Directions for developing policy strategies follow from these principles. The role of health services in influencing the distribution of health in populations is discussed in the special context of primary-care-oriented health systems that are, at the same time, more effective, more efficient, and more equity producing than is the case for specialist-dominated health systems. History of the Concept of Equity in Health The beginning of interest in equity in health is difficult to pinpoint. Cer - tainly, the issue of social disparities in health has a long history, dating back in modern history at least to the writings of Frederick Engels, who, in 1845 in The Condition of the Working Class in England, asked, "How is it possible . . . for the lower class to be healthy and long-lived? What else can be expected than an excessive mortality, an unbroken series of epidemics, a progressive deterioration in the physique of the working population?" (128). Impetus to the policy relevance of social determinants of health was provided by the Black report. This report, titled Inequalities in Health

The need to demonstrate that health care has an influence on health status is increasingly pressing. Such demonstrations require tools of measurement which are unfortunately not available. Development of instruments has been hampered by a lack of consensus on appropriate frames of reference, and there appears to be little agreement on what should be measured and what relative importance should be ascribed to different dimensions of health status. An approach that does not require the assignment of numerical values or weights to various aspects of health status and is applicable to all age groups within the population and to the whole spectrum of health problems rather than to specific medical diagnoses would seem desirable. A scheme that is based upon the development of a “profile” rather than a single “index” for describing health status is proposed in this paper. The model is a conceptual framework whose usefulness will depend upon efforts of a large number of researchers from many disciplines to develop instruments which can be incorporated in it. Although the problems in development of the scheme are complex, I hope that it will focus attention on the relevant dimensions and facilitate improved coordination of efforts to produce ways to demonstrate what health care contributes to health.

This study compared community-governed nonprofit and for-profit primary care practices in New Zealand to test two hypotheses: (1) nonprofits reduce financial and cultural barriers to access; and (2) nonprofits do not differ from for-profits in equipment, services, service planning, and quality management. Data were obtained from a nationally representative cross-sectional survey of GPs. Practices were categorized by ownership status: private community-governed nonprofit or private for-profit. Community-governed nonprofits charged lower patient fees per visit and employed more Maori and Pacific Island staff, thus reducing financial and cultural barriers to access compared with for-profits. Nonprofits provided a different range of services and were less likely to have specific items of equipment; they were more likely to have written policies on quality management, complaints, and critical events, and to carry out locality service planning and community needs assessments. The findings support the shift to nonprofit community governance occurring in New Zealand and elsewhere.

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

Primary care services provide continuing and coordinating care, cater to most health care needs, and serve as a point of first contact with the health system. This article addresses the issue of government ownership of primary care. Ownership confers governance responsibility (ultimate control) for an organization, and accountability for its actions. Primary care organizations can be classed as government owned and operated or privately owned and operated, the latter with or without community governance. The authors address two policy questions: Does the ownership form of a primary care organization matter? What ownership frameworks should be used to guide policy-making? Arguments for and against government ownership are examined from political and economic perspectives, informed by a governance framework. Government ownership of primary care may solve problems associated with private for-profit ownership that are related to lack of control of strategic assets, lack of direct political accountability, contracting, and market failure, but it may raise potential problems of lack of responsiveness to minority and local needs and capture by interest groups. In response to the problems associated with government ownership, community-governed private nonprofits have an essential role as a vehicle for indigenous self-determination, catering for minority populations, experimenting with policy options, and providing public goods particularly for minority populations. The authors argue that private organizations that lack community governance have a lesser role.

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.

To analyze the reliability and validity of the domains of the Child Health and Illness Profile-Child Edition Parent Report Form (CHIP-CE/PRF) included in the Barcelona Health Survey conducted in 2000 and to obtain population-based reference values.Data were obtained from proxy-respondent interviews of children aged 5-14 years old (n = 836) participating in the Barcelona Health Survey 2000. The 4 subdomains of the parent version of the CHIP-PRF included in the health survey were: satisfaction with health, and physical discomfort, emotional discomfort, and limitation of activities of the discomfort domain. Internal consistency was assessed using Cronbach's alpha coefficients. An exploratory factor analysis was carried out and analysis of covariance was performed to assess the construct validity of the subdomains.In all the subdomains assessed, Cronbach's alpha was above 0.70 (range, 0.76-0.98). In the factorial analysis, almost all the items (31/35) presented the highest load in their corresponding subdomain. Most of the expected mean differences among groups were confirmed. Girls aged 10-14 years old scored the lowest, both in satisfaction with health (48.93; 95% confidence interval [CI 95%], 47.40-50.47) and in discomfort (48.87; CI 95%, 47.51-50.22). No differences were found according to the social class of the head of the family.The present study provides a useful measure of perceived health status in a child health survey.

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.

Objective This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO. Methods Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics. Results After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance. Conclusion Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

OBJECTIVES. To assess the structural, convergent, discriminant, and criterion validity of the Spanish version of the Child Health and Illness Profile–Adolescent Edition (CHIP-AE) and to compare results with the U.S. version. SUBJECTS. A sample of adolescents aged 12 to 19 attending schools and representative of the school-aged population in Barcelona, Spain (n 902). MEASURES. Exploratory factor analyses were performed, and results compared with the U.S. version. The Child Depression Inventory (CDI) and the State-Trait Anxiety Inventory (STAIC) were administered to a subgroup of adolescents to assess convergent and discriminant validity. Criterion validity was assessed by using receiver operating characteristic (ROC) curves to examine the ability of the CHIP-AE academic performance subdomain to predict school grades. RESULTS. The Spanish version has 6 defined domains with a factor structure showing minor differences from the U.S. version. Higher correlations were found between the CDI and STAIC and CHIP-AE subdomains of emotional discomfort and self-esteem (range. 0.48 – 0.80, P

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.

The nonrandom distribution of ill health across and within populations is cause for ethical concern. Systematic differences in health across populations and subpopulations are a result of interactions among many types of influences operating on broad ecological, community, and individual levels. The operation of this web of influences potentiates health disadvantage for some populations and subpopulations and, conversely, enhances resilience to health threats in more advantaged populations. Understanding the genesis of inequity requires an appreciation of the dynamics of these interactions. Thus, research directed at elucidating the causes of inequity in order to facilitate policy changes requires the adoption of conceptual frameworks to guide more efficient and effective future scientific inquiry concerning this worldwide imperative.

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.

To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer.Prospective cohort study.All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states.Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists.Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist.Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Study objective: To review existing data on social class gradients in adolescent health and to examine whether such gradients exist in new data concerning US adolescents. Design: Review of relevant publications and unpublished data; regression analyses using adolescent self reported health status data to determine whether there are gradients by social class, using three classes categorised by adolescent reported parental work status and education. Participants: Adolescents of ages 11–17. Main results: Findings from the literature indicate the presence of social class gradients in some but not all aspects of adolescent health. Results from new data showed social class gradients in several domains of health and in profiles of health. The likelihood of being satisfied with one9s health, of being more resilient (better family involvement, better problem solving, more physical activity, better home safety), having higher school achievement, and of being in the best health profiles were significantly and progressively greater as social class rose. Moreover, the probability of being in the poorest health profile type group was progressively higher as social class declined. Conclusions: The review of existing data and the new findings support the existence of social class gradients in satisfaction with one9s health, in resilience to health threats, in school achievement, and in being in the best health overall (as manifested by the health profiles composed of four major domains of health). The study had two especially notable findings: (1) the paucity of studies using the same or similar indicators, and (2) the consistent existence of social class gradients in characteristics related to subsequent health, particularly intake of nutritional foods and physical activity. The sparseness of existing data and the different aspects of health investigated in the relatively few studies underscore the need for (1) the development of conceptual models specifically focused on adolescent health and social class; (2) additional inquiry into the measurement of social class and adolescent perceptions of class; (3) inclusion of contextual variables in study design; and (4) longitudinal cohort studies to better understand the specific determinants of health during adolescence.

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.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.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.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.

Equity in health and health care have become important priorities for the world. If efforts at achieving equity are to have any basis in evidence concerning which strategies are likely to work, a research agenda is necessary. An adequate research agenda requires a knowledge of what the problem is, an understanding of the genesis and correlates of the problem, methods to measure these correlates, and rigorous testing of alternative explanations and interventions. This article presents a working definition of equity in health and health services, a conceptual framework in which to view the various types of influence on health and distribution of health in populations, a summary of evidence on the effects of some of these categories, and a research agenda for guiding efforts to improve knowledge on which to base interventions that enhance the attainment of equity. Because of their relative neglect in the existing literature on equity in health, the special roles of political forces and of primary care as a particularly key element of health services are stressed.

Primary care has not secured a firm place within the US health services system. Since primary care lacks a strong research base, is not institutionalized in medical education or in policy-making and is marginalized in both proposed and actual reforms, it has not developed into a central component of the health care infrastructure. We discuss recent efforts that promised modest improvements, including the Clinton health care reform proposals and subsequent federal and state actions, in the role of primary care within the health services system. We also assess the likely fate of primary care given the accelerated growth of managed care and market competition, the dissatisfaction of large segments of the population with managed care and misperceptions of managed care as synonymous with primary care. We highlight how managed care fails to achieve the cardinal functions of primary care and summarize initiatives that, at a minimum, would be required to secure a stronger position for primary care in the future.

ContextMost health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.ObjectivesTo comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.DesignRetrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.Main Outcome MeasuresSelf-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.ResultsOverall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.ConclusionsHaving the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.

Evidence of the benefits of primary care is robust1,2. Primary health care as a unique delivery system entity provides more effective, equitable, and efficient care and, as a clinical mode of health services delivery, its four functions of primary care (first contact, person-focused care over time (“longitudinality”), comprehensiveness of services, and coordination) have demonstrable beneficial effects on a variety of health-related phenomena including better recognition of patients’ problems, more accurate diagnosis, better concordance with appointment keeping and with treatment advice, less emergency department use, fewer potentially avoidable hospitalizations, better generic (not specifically disease-oriented) prevention, better monitoring of abnormalities, fewer medication prescriptions, and fewer unmet needs3. The benefits are much greater when the primary care provider is the same individual over time, as compared with a relationship with a particular place, except for preventive care (presumably because the need for routine preventive care is easily documented by transfer of information by means other than interpersonal contact, e.g., medical records)3. What is it about “regularity” of care that might contribute to one or more of these functions of primary care? The study by Einarsdottir and colleagues4 was predicated on the assumption that regular contact with a general practitioner facilitates early symptom recognition and consequent adjustment of treatment as needed. Does regularity of care facilitate early problem recognition? For it to work in this way, the “regularity” would have to involve consistency of care over time with a particular practitioner. As noted above, the benefits of longitudinality are much greater when it is provided by a particular practitioner rather than merely with a particular place. Although symptom recognition is rarely (if ever) a target of efforts to improve quality of care, it is a critical and rate-limiting step to the other processes of clinical intervention: adequate diagnosis, management, and reassessment. It takes knowledge of a patient (rather than just a disease or type of disease) to achieve better problem recognition5. When patients and their clinicians agree on what the patients’ problems are, the patient is more likely to be improved on follow-up whether judged by the patient or the practitioner. Recognition of patients’ problems from one time to another is best when the same practitioner is involved both times, less well when the same type of practitioner (e.g., physician-physician, nurse-nurse) is involved, even less well when a nurse follows up after a physician, and worst when a physician follows-up after a nurse)5. Therefore, there is some justification for the assumption that regular care would facilitate problem recognition if the provider is familiar with the patient as a result of a long-term relationship. In the study by Einarsdottir et al., there is no information on whether the care is usually or always provided by the same practitioner; the regularity observed in the data set only reflects the duration of time between visits. Wolinsky and colleagues 6 recently showed that non-continuity of the primary care physician, as defined as more than eight months between visits to the same primary care physician, is associated with increased mortality over a fifteen year period in individuals 70 years of age or older. We cannot be sure that the benefit of “regularity” is a result of the establishment of better interpersonal relationship over time without knowing whether the practitioner remains the same. Would the same effect have been observed if the regular contact had been by phone, by mail (email or otherwise), or by routine follow-up with an unfamiliar auxiliary health worker who might change from time to time? Certainly, any of these mechanisms would have been less costly than a face-to-face visit with a physician. The findings of this study provide a powerful impetus to explore the mechanism(s) by which the benefit of regularity of visits occurs and the different ways of achieving it. Does it depend on the frequency of visits? On the continuity of the practitioner? Or just the effect of periodic contact? (And if so, what should the “period” be? Some of the findings are puzzling. Why was there no dose-response effect in which the more the regularity, the better the outcomes? For neither mortality nor hospitalization is there a clear gradient effect. Is the comorbidity measure an adequate one? Subsequent studies could use measures that outperform the Charlson index along clinically relevant dimensions7. Key outcomes (hospitalizations and premature death) are likely to be influenced substantially by the nature of the medication used. It appears that the main benefit of regular visits on risk of hospitalization is among patients prescribed low doses of inhaled corticosteroids, either with or without long-acting bronchodilators. The effects of regular care on all-cause mortality are unimpressive, as they fail to show a dose-response effect (more regular care associated with lower death rates) when the patients were stratified by the type of medication. In fact, those on short-acting bronchodilators who have more regular care seem to have higher all-cause mortality. In seeking to learn about the effects of “regularity” on monitoring of medications over the long term, we should ask if regularity can avert adverse events in people with and without comorbidity and prevent medication-related adverse events among those who do and those who do not adhere to protocols. An important contribution of this paper is the insight that chronic illnesses have acute manifestations requiring much more than routine monitoring. There is nothing about chronic illnesses that makes them unlike acute illnesses in their need for ongoing responsiveness to patients’ needs. The now-vast literature on the management of chronic conditions neglects acute exacerbations. Virtually all of the studies of the impact of strategies such as the Chronic Care Model (CCM) leave the impression that the major challenge of management is monitoring to assure compliance with medication and self-care management. This study explicitly raises the issue of early warning signs that have received little attention in the chronic care management literature. Perhaps subsequent analyses of the data can help to understand the mechanism of the effect of regular care. Is the benefit equity-producing, that is, preferentially beneficial to people with more limited social means, or is it disparity-creating because of being more easily used by people with fewer social needs? Is the benefit equal for those whose regular visits are initiated by the health professionals and for those who are simply encouraged to seek early care when they develop symptoms? Is it possible to distinguish visits that are regularly scheduled by providers for “checkups” from those that are at the initiation of the patient? In which situation is the benefit greatest? The study provided no information on the mechanism for achieving regularity. Did it occur by providing set appointments for patients or was it achieved by encouraging patients to return as soon as possible when they think they are experiencing a problem? Is there an added benefit from pre-set appointments, as compared with making appointments more easily available? The nature of visits to primary care is changing, at least in the US; about half of all visits to general internists are now for routine follow-up8, but there is little evidence that routine care is uniformly beneficial. Greater benefit might be achievable by mechanisms that rely on better responsiveness of practitioners to patient-perceived problems – the essence of patient-centered care over time. What about the influence of regularity of primary care on number and type of specialist visits? Are they increased, decreased, or unchanged when there is greater regularity of primary care visits? In view of the increasing use of specialists in the US health services system, this is an important issue. The more primary care physicians that are seen, even after controlling for number of visits, the greater the use of specialists and the greater the use of all types of resources and costs9. Does it matter if the effect of regularity is with a variety of primary care doctors and/or specialists? One (presumably unexpected) effect of a chronic care model demonstration was an increase in referrals to specialists10. The authors of this study are to be commended for raising a new issue in health services research. They have scratched the surface of a potentially important mechanism for improving care. But the absence of a clear gradient in benefit from least regular to most regular raises questions about potential mediating variables. There is more work to be done to explain and explore the nature of the effects and their modifiers. Does regularity achieve benefits through better knowledge of the whole patient, better ability to detect deviations from everyday symptoms, more rapid response to symptoms, better knowledge and management of co-existing morbidity, better management of ancillary resources, better responsiveness of patients to recommended interventions, better ability of patients themselves to challenge care that does not seem right to them, better acceptance of needed changes in daily activities, better awareness among patients of worsening symptoms, all of the above, or something else? We need no further demonstrations of the benefits of person-centered care over time. What we need now is to know whether these achievements are better accomplished with more routine care or with better and more rapid responsiveness to patients’ problems, and what types of professionals are best for these aspects of primary care.

To describe how physicians coordinate patient care for specialty referrals and to examine the effects of these activities on referring physicians' satisfaction with the specialty care their patients receive and referral completion.Prospective study of a consecutive sample of referrals (N = 963) made from the offices of 122 pediatricians in 85 practices in a national practice-based research network. Data sources included a physician survey completed when the referral was made (response rate, 99%) and a physician survey and medical record review conducted 3 months later (response rate, 85%). Referral completion was defined as receipt of written communication of referral results from the specialist.Pediatricians scheduled appointments with specialists for 39.3% and sent patient information to specialists for 50.8% of referrals. The adjusted odds of referral completion were increased 3-fold for those referrals for which the pediatrician scheduled the appointment and communicated with the specialist compared with those for which neither activity occurred. Referring physicians' satisfaction ratings were significantly increased by any type of specialist feedback and were highest for referrals involving specialist feedback by both telephone and letter. Elements of specialists' letters that significantly increased physician ratings of letter quality included presence of patient history, suggestions for future care, follow-up arrangements, and plans for comanaging care; only the inclusion of plans for comanaging patient care was significantly related to the referring physicians' overall satisfaction.Better coordination between referring physicians and specialists increases physician satisfaction with specialty care and enhances referral completion. Improvements in the referral process may be achieved through better communication and collaboration between primary care physicians and specialists.