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Primary care reform is now a worldwide imperative. National health care systems with strong primary care infrastructures have healthier populations, fewer health-related disparities and lower overall costs for health care. [1][1] In the World Health Organization’s 2008 World Health Report, [2][2]

Objective. In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Medicaid insurance plans. Design/Participants. We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 36 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on referred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 months after their referral was made. Results. Gatekeeping arrangements were common among children and adolescents with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeeping plans were more likely to be referred with private (3.16% vs 1.85% visits referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental requests for specialty care among gatekeeping patients did not explain the increased referral rate. Physicians' reasons for making the referral were similar between the two groups. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans. However, rates of physician awareness that a specialist visit occurred and specialist communication back to pediatricians did not differ between the two groups 3 months after the referrals were made. Conclusions. Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arrangements increase referrals from pediatricians' offices to specialty care and compromise some aspects of coordination.

Health Services Research, by now a mature field, has never developed precise terminology for most of the characteristics of health systems and services. Like Alice, its practitioners use terms to mean what they want them to mean, no more, no less. So it is with access. Everyone knows that, above all, people need "access" to health services to benefit from whatever health services have to offer. But what does "access" mean? Access, according to proper usage, is a noun meaning "a means of approaching or nearing a 'passage.'" People have access. "Accessible" is an adjective, meaning easily approached or entered; services can be said to be accessible if they have characteristics that make it possible for people to get to them. That is, places have varying degrees of accessibility, but people have varying degrees of access. So far, so good. What about "realized access," which is usually assumed to be synonymous with "utilization?" As characteristics other than access influence use, it confuses things to equate access with utilization. The paper by Jennifer DeVoe et al entitled, "A Usual Source of Care: Supplement or Substitute for Health Insurance Among Low-Income Children," deals with "access," but not only access.1 It builds on previous evidence in showing the importance of both health insurance (a measure of financial "access") and a source of primary care (which may vary in its accessibility) as policy strategies.2'3 Their paper attempts to tease out the relative advantages of each. The data indicate that, compared with children having both insurance and a regular source of care, insured children without a usual source of care had higher rates of unmet medical needs, no doctor visits in 12 months, and problems obtaining specialty care. On the other hand, having no health insurance but having a regular source of care predicted a higher likelihood of being unable to get timely urgent care, needed counseling, prescriptions, and having more problems obtaining dental treatment. Not all of the variables used to assess the impact of insurance and usual source of care are "access" variables. "Problem getting specialty care" would be expected to have more do to with having a usual source of care (and even MORE to do with the characteristics of that usual source) because of the need for referral in many health systems and specialty facilities. Similarly, "problem getting counseling" has more to do with the nature of the usual source of care than with "access." "Meeting needs" is certainly a characteristic of the quality of care received, undoubtedly at least as much as it is an "access" phenomenon. Dental services would not be expected to be related to usual source of care, as most "usual sources" do not provide it; it would be expected to be related to ability to pay (insurance). Insurance itself is an imprecise terms. In the United States, where most of 'insurance' is in the private market and there are innumerable variations in what insurance coverage and at what price, simply having insurance does not guarantee the ability to obtain needed care. Understanding the dynamics of these processes requires thinking about pathways. It has been almost 50 years since Avedis Donabedian suggested that it would be helpful to characterize phenomena in health services as structure, process, or outcome, and to examine the impact of structure on process and both on outcomes.4 It has been 35 years since the New England Journal of Medicine published a special article on the specific components of structure, process, and outcome, which showed how greater understanding

The purpose of this study was to assess the role of needs and social factors in the use of health services among children under age 15 in Catalonia, Spain, where health care reform was explicitly designed to facilitate universal access to primary care according to health needs. Data from the Catalan Health Interview Survey of 1994, a multistage probability sample (2,433 children under 15 years old), were analyzed. Multiple regression examined the relationship between health needs and number of visits in the last year, controlling for the effect of sociodemographic characteristics. Two logistic regression equations were selected to predict heavy (more than seven visits per year) and light (less than two visits) utilization of services. The multiple regression model explained 14.3 percent of the variance in number of visits, with health status perception, disability, reported chronic condition, restriction of activities, and having had a recent accident by far the most important determinants. No familial socioeconomic characteristics, including social class, education, or family size, influenced the extent of use. In contrast to health systems not designed to achieve either universal access according to need or strong primary care, universal access to health services in Catalonia appears to enhance the use of services among children with health needs, regardless of socioeconomic characteristics.

OBJECTIVES: This study examined the relationship between access and use of primary care physicians as sources of first contact and continuity with the medical system. METHODS: Data from the 1987 National Medical expenditure Survey were used to examine the effects of access on use of primary care physicians as sources of first contact for new episodes of care (by logistic regression) and as sources of continuity for all ambulatory visits (by multi-variate linear regression). RESULTS: No after-hours care, longer office waits, and longer travel times reduced the chances of a first-contact visit with a primary care physician for acute health problems. Longer appointment waits, no insurance, and no after-hours care were associated with lower levels of continuity. Generalists provided more first-contact care than specialists acting as primary care physicians, largely because of their more accessible practices. CONCLUSIONS: These data provide support for the linkage between access and care seeking with primary care physicians.

Objectives. The aim of this study was to develop a taxonomy of health profile-types that describe adolescents' patterns of health as self-reported on a health status questionnaire. The intent was to be able to assign individuals to mutually exclusive and exhaustive groups that characterize the important aspects of their health and need for health services. Methods. Cluster analytic empirical methods and clinically based conceptual methods were used to identify patterns of health in samples of adolescents from schools and from clinics that serve adolescents with chronic conditions and acute illnesses. Individuals with similar patterns of scores across multiple domains were assigned to the same profile-type. Results from the empirical and conceptually based methods were integrated to produce a practical system for assigning youths to profile-types. Results. Four domains of health (Satisfaction, Discomfort, Risks and Resilience) were used to group individuals into 13 distinct profile-types. The profile-types were characterized primarily by the number of domains in which health is poor, identifying the unique combinations of problems that characterize different subgroups of adolescents. Conclusions. This method of reporting the information available on health status surveys is potentially a more information way of identifying and classifying the health needs of subgroups in the population than is available from global scores or multiple scale scores. The reliability and validity of this taxonomy of health profile-types for the purposes of planning and evaluating health services must be demonstrated. That is the purpose of the accompanying study.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Purpose: To determine the accuracy of adolescents' self-report of health insurance coverage, using parents' report as a comparison standard. Methods: Two separate samples of urban, school-based adolescents and their parents completed self-administered questionnaires about type of health insurance coverage. Sample 1 included 123 and Sample 2 included 93 adolescent–parent pairs. Percent agreement and the kappa statistic were determined for each of the sample groups, and for males versus females and older (>14 years) versus younger (≤14 years) adolescents. Results: In Sample 1, 33% of adolescent respondents responded "don't know" to the question about type of insurance coverage, and 4% left the question blank; in Sample 2, 3% answered "don't know," with none leaving the question blank. For Sample 1, we found a 57% rate of agreement of adolescents with their parents, and a corresponding kappa of .21. Females and older subjects demonstrated greater accuracy, with kappa's all in the range .13–.29. In Sample 2, 73% of subjects agreed with parents' report, with a kappa of .48. Females and older subjects also demonstrated greater accuracy, with the highest kappa of .59 demonstrated by older females. Excluding those responding with "don't know," we found overall percent agreement with parents of 87% in Sample 1 and 73% in Sample 2; the corresponding kappas were .47 and .51. Females demonstrated higher agreement with parents in both samples. The results stratifying by age were inconsistent. In Sample 1, privately insured subjects were more accurate reporters than those either on medical assistance or uninsured. In Sample 2, no differences were seen by type of insurance. Conclusions: Many adolescents do not know their health insurance coverage status. However, for those who did claim to know, acceptable rates of accuracy using both percent agreement and the kappa statistic were demonstrated. Further research is needed to determine how information about insurance is communicated to adolescents and how this knowledge affects access to and use of health services.

The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on how the day-to-day practice of primary care for children has changed during this period.To identify aspects of primary care practices for children that are undergoing substantial changes.Analysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1985, and 1989 to 1994.Primary care practitioners recorded data on 58,488 child visits. MAIN OUT COME MEASURES: Characteristics and insurance status of children, physician activities during visits, and disposition after visit.Child visits to primary care physicians increased by 22% between 1979 and 1994. The mean age of children visiting primary care physicians decreased from 6.7 years in 1979 to 5.7 years in 1994 (P for trend,.001). The ethnic diversity of child visits increased primarily as a result of an increasing proportion of visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend,.001) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend,.001). Medicaid and managed care increased dramatically as sources of payment. Changes in physician activities included an increase in some preventive services, changes in the most commonly encountered medications, and an increased mean duration of patient visits (11.8 minutes in 1979 to 14.2 minutes in 1994, P for trend,.001).These data may assist in the development of educational and research initiatives for physicians caring for children. The declining proportion of adolescent visits may present physicians with challenges in the care of adolescents. Physician prescribing practices showed changes without evidence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased mean duration of primary care visits. The increased duration of child visits may conflict with the managed care emphasis on physician productivity.

Different approaches to health reform are proposed in many countries to overcome inefficiencies in care delivery. This paper assesses an incremental reform initiated in Spain 10 years ago, which sought to improve the efficiency of the entire health system through changes in the organization and delivery of primary care. In this study, aspects of accessibility, comprehensiveness, longitudinality and technical quality of reformed versus unreformed care were assessed for respondents to a household interview survey conducted in the Basque Region of Spain in 1992. According to this study, aspects of care such as longitudinality and technical quality seemed improved with the reform, whereas other aspects such as accessibility and comprehensiveness remained unchanged. The authors conclude that system related characteristics (more associated with access and comprehensiveness) may be impeding the achievement of the goals of the reform and argue that attempts to encourage more autonomy of care delivery may be required.

Health care reform in the United States and elsewhere raises many questions about equity and effectiveness of health services. Although the impetus has been cost containment, the reforms have often been justified on the grounds that they will enhance primary care. In this article, health care reform efforts are divided into two types: market-driven, demand-based systems versus systems predicated on meeting population health needs. The two “scenarios” are contrasted with regard to their likely impact on the attainment of primary care characteristics: first-contact care, longitudinality, comprehensive services, and coordination. Since the ultimate outcome of these reforms cannot be predicted, there is compelling need for evaluating them as they proceed.

Objectives. Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy. Methods. Population: 2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study. Data: 1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome. Results. Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school. Conclusions. Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated.

This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program.The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period.The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P0.05) for asthma than low-cost providers. There was no statistically significant (P0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers.Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.

Most studies of ambulatory care quality are based on chart reviews of episodes of care in single settings, rather than on care received by a patient over time and across settings. The purpose of this study was to compare ambulatory care quality scores based on information from the usual source of care to scores based on information from all providers seen during a year. The quality of well child care for 55 two-year-olds and asthma care for 70 children and adults continuously enrolled in the Maryland Medicaid program throughout 1988 was assessed. Combining data from multiple providers changed quality scores in both directions. For well child care, quality scores generally improved because of an increased opportunity to perform desirable actions, such as lead screening. However, quality scores for asthma care generally decreased because undesirable clinician actions, such as the failure to document follow-up plans, increased as more problems were uncovered. Thus, the findings of quality assessments differ according to whether the focus is on care delivered by individual providers or on care received by patients. The direction of the difference will depend upon whether the indicators of quality represent omission of recommended care or commission of improper care. Copyright © 1996 Elsevier Science Ltd.

Background : Studies in the United States have demonstrated that rates of hospitalization for conditions sensitive to primary care are related to socioeconomic factors. Our objective was to identify those sociodemographic and primary care factors associated with pediatric hospitalization for ambulatory care-sensitive conditions, in a country (Spain) with a health system that provides universal coverage. Methods : Cross-sectional survey of 504 children hospitalized in a District General Hospital in Valencia, Spain. Data were gathered on sociodemographic variables, type of physician providing primary care and ambulatory care use prior to hospitalization. Analysis consisted of bivariate statistical tests and logistic regression techniques. Results : Children who were under 2 years old and female were at significantly higher risk for hospitalization due to ambulatory care-sensitive conditions. Socioeconomic variables, type of physician or a previous visit to primary care services were not associated with a different risk of hospitalization due to these conditions. Conclusion : Characteristics unrelated to difficulties in access, or to type of provider, influence the risk of hospital admissions for conditions that could be prevented or managed without hospitalization. More specific classification of conditions potentially could be useful for determining which factors of structure or process of health services are related to hospitalization.

OBJECTIVES. This study investigated the association between health care systems and health indicators in developed countries. METHODS. Cross-national comparisons were conducted with regression analysis between 17 Western European countries with two types of health care systems: national health services and social security systems. RESULTS. Health care expenditures were inversely correlated to potential years of life lost to females and to infant mortality rates; they were positively correlated to life expectancy for females. Regression models predicted that countries with national health services systems would have lower infant mortality rates at similar levels of gross domestic product (GDP) and health care expenditures. Finally, increases in health care expenditures would decrease the ratio of observed to predicted infant mortality rates according to GDP; this decrease would be greater in countries with national health services than in those with social security systems. The model predicted this difference to be about 13% at average levels of health expenditures. CONCLUSIONS. National health services seem to be more efficient at producing lower infant mortality rates than social security systems in Western European countries.

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11-17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

Knowledge about primary care has been accumulating at a rapid rate. We know what primary care is and what it does; in contrast, we know almost nothing about specialty care, except for that part of it that takes place in the inpatient setting, and even that knowledge is spotty and unrepresentative. Professor Pereira Gray has posed a remarkable hypothesis: that there is role reversal between specialists and primary care physicians in that primary care physicians can now claim responsibility for a considerable proportion of lifesaving care, whereas specialists are increasingly assuming the role of ‘remediators’. There is much to ponder in his short exposition. His hypothesis is provocative. Can it be supported with evidence? 1

Meeting of the International Society for Equity in Health, Havana, Cuba, June 2000 This issue of the Journal of Epidemiology and Community Health contains seven contributions that were originally presented as submitted papers to the first meeting of the International Society for Equity in Health, held in Havana, Cuba, in June 2000. These contributions, consisting of seven original scientific papers and the keynote address (by Sudhir Anand) are complemented by an additional set of “keynote vignettes” (also presented at the same meeting) to be published in subsequent issues of the journal. (They are short essays on priorities for research on equity in health, prepared by noted researchers in the field.) The studies reported cover a wide variety of specific topics within the broader topic of equity in health. Two of the eight deal specifically with the meaning of equity in the context of health1,2; two address inequities in health …

Inequity is the presence of systematic and potentially remediable differences among population groups defined socially, economically, or geographically [1,2]. It is not the same as inequality, which is a much broader term, generally used in the human rights field to describe differences among individuals, some of which are not remediable (at least with current knowledge). Some languages do not make a distinction between the two terms, which may lead to confusion and a need to clarify exact meaning in different contexts. Some people use the term "unfairness" to define inequity, but unfairness is not measurable and therefore not a useful term for policy or evaluation. Inequity can be horizontal or vertical. Horizontal inequity indicates that people with the same needs do not have access to the same resources. Vertical inequity exists when people with greater needs are not provided with greater resources. In population surveys, similar use of services across...

RECENT history reflects a myriad of problems with the US health service system. In the 1960s, physician manpower shortages received the most attention from policymakers. When efforts to increase the number of physicians succeeded, maldistribution was recognized as a problem. In the 1970s, rapid increases in costs attracted attention and led to the development of several regulatory mechanisms, including the diagnosis related groups, to reduce expenditures associated with hospitalization. In the 1980s, observations of variations in physician practice patterns without concomitant variations in outcomes of care led to a realization that much of medical care lacked benefit, and the movement toward quality control and total quality improvement assumed prominence. In the 1990s, compromised access resulting from the absence of universal health insurance and excessive costs consequent to unnecessary care share the stage in the policy drama. See also p 3156. The poor development of primary care within the US health

PURPOSE To examine the choices of career paths of women in internal medicine, specifically to determine (1) whether women continue to prefer primary care practice more often than men do and (2) whether differences in career paths between men and women result from differences in the natures of the training programs they complete. METHOD A database containing demographic, training, and clinical-practice information on 19,151 physicians (3,569 women and 15,582 men) who had been trained in internal medicine was constructed by merging data from the National Resident Matching Program matches in internal medicine for 1977-1982 with data from the 1985 American Medical Association Physician Masterfile, which contains physician practice profiles. RESULTS Similar percentages of the men and the women chose primary care residencies (8% versus 9%, ns) and trained in the 100 major medical centers (49% versus 50%, ns). The women more frequently trained in programs affiliated with medical schools in the top prestige quartile (38% versus 33%, p < .05). The attrition rates of residents who left their training for careers in other medical fields were the same for the men and the women (14%). Fewer women obtained board certification (74% versus 80%, p < .01). The women chose to practice general internal medicine more frequently than did the men (52% versus 45%, p < .0001), regardless of the training program completed (primary care or traditional). CONCLUSION The women pursued primary-care-oriented internal medicine to a significantly greater degree than did the men, regardless of the type of training program completed (primary care or traditional).

This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Pysician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspeciality practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecilaty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.

British primary care is said to be the envy of the world. The spirit of experimentation anchored to a sound foundation of care led by general practitioners provides other countries with examples of accessible services, continuity of care, and innovative payment systems. Although Britain's healthcare statistics are not the best in the world they are far better than expected given the comparatively low funding of the healthcare system and the relatively inadequate systems of social support. Seen from the outside, Britain has clearly done something right with its National Health Service, which is based on and increasingly strengthened by its infrastructure of primary care. The key features of a strong, functioning primary healthcare system are the ability to provide continuity of care and a comprehensive financing system. Until now continuity of care has existed in the United Kingdom because every patient is registered with a general practitioner (a patient list system). People thus have the possibility of developing a long lasting relationship with a general practitioner of their choice, increasing the likelihood of satisfaction among patients.1 A relationship based on personal doctoring has multiple …

The clarification by Dr. Glazier is appropriate. Although controlling for patient characteristics eliminates and explains the reason for the excess use of emergency care in rural areas, the fact is that there is something different about the needs of people in rural areas for emergency care services

Background In contrast to the considerable evidence of inequitable distribution of health, little is known about how health services (particularly primary care services) are distributed in less developed countries. Using a version of primary health care system questionnaire, this pilot study in Thailand assessed policies related to the provision of primary care, particularly with regard to attempts to distribute resources equitably, adequacy of resources, comprehensiveness of services, and co-payment requirement. Information on other main attributes of primary health care policy was also ascertained. Methods Questionnaire survey of 5 policymakers, 5 academicians, and 77 primary care practitioners who were attending a workshop on primary care. Descriptive statistics with Fischer's exact test were used for data analysis. Results All policymakers and academicians completed the mailed questionnaire; the response rate among the practitioners was 53.25% (41 out of 77). However, the responses from all three groups were consistent in reporting that (1) financial resources were allocated based on different health needs and special efforts were made to assure primary care services to the needy or underserved population, (2) the supply of essential drugs was adequate, (3) clinical services were distributed equitably, (4) out-of-pocket payment was low, and that some primary health care attributes, particularly longitudinality (patients are seen by same doctor or team each time they make a visit), coordination, and family- and community-orientation were satisfactory. Geographical variations were present, suggesting inequitable distribution of primary care across regions. The questionnaire was robust across key stakeholders and feasible for use in a transitional country. Conclusion A primary care systems questionnaire administered to different types of health professionals was able to show that resource distribution was equitable at a national level but some aspects of primary care practice across regions is still of concern, in at least in this transitional country.

This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.

U.S. primary care is in crisis. Primary care physicians must care for more and more patients, with more and more chronic conditions, in less and less time, for which they are compensated far less than subspecialists. They must absorb increasing volumes of medical information and complete more paperwork than ever, as they try to function in a poorly coordinated health care system. As a result, their ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields. In a roundtable discussion moderated by Dr. Thomas Lee, four experts in primary care and related policy — Drs. Thomas . . .

The impact of record format on provider performance and recording of the process of care and their concordance were examined in this study. The process of care was defined by existing sets of explicit criteria developed for quality assessment. The study was conducted in an urban teaching hospital pediatric primary care clinic. Housestaff were encouraged, but not required, to use the clinic's structured, age-specific forms for recording well-child care. Performance and recording were compared during required well-child visits using the structured form and those using the basic clinic form. Study data from 1031 visits to 68 housestaff during a 14-month period were collected using medical record abstracting of all visits and direct observation of 243 of them. Twenty-three of the providers were assigned randomly to an unobserved control group to assess the effect of observation on recording. Use of the structured form was associated with significantly higher levels of both recorded and observed performance. When performance could be merely checked off to document performance, overdocumentation was found. Record-based estimates of performance were more accurate during visits when the structured form was used. Record format can improve provider performance and recording of the process of care.

Further to the three research areas Fortin et al identify for investigation,1 four additional aspects of multimorbidity are also relevant. Firstly, acute conditions also contribute to comorbidity, and there is no reason for their exclusion. Secondly, comorbidity is of particular relevance to primary care, which is person focused and not disease focused.2 Thirdly, research on the …

The article "Patient-Physician Agreement About Medical Diagnoses and Cardiovascular Risk Factors in the Ambula­ tory General Medical Examination" in this issue of the Mayo Clinic Proceedings (pages 1131 to 1137) adds one more bit of evidence to the small but consistent body of data demon­ strating discordance between physicians and patients. At least half the time, these two parties in the process of health care do not agree on what the patient's problem is, even when liberal criteria are applied to characterizing the prob­ lem. In their report, the authors present a frankly physician­ oriented view of the importance of the patient's problem, designating the physician's view as the "gold standard" and using their own opinion to characterize the severity and importance. A less physician-oriented view would take note of the potential absence of reference to the 25% of all prob­ lems that are mentioned only by the patient and not recog­ nized at all by the physician. 1 If it is true, as evidence suggests, that physician-patient agreement contributes to good outcomes,' what can be done to understand the reasons for lack of concordance, and how can the information be used to improve the situation? The vast literature on compliance documents repeatedly that merely "telling patients" achieves, at best, only a 30% suc­ cess rate.' Patients must be more involved in decisions about their own medical care, including the important aspects of defining their problems. Despite the high degree of current interest in patient empowerment in decision making about the choice of appro­ priate interventions.v' little is known about the extent to which patients have any influence in defining the nature of their own illnesses. Perhaps many patients have minimal concern about the specific medical label attached to their problems, even though medical dogma makes it an all-im­ portant component of high-quality care. When all is said and done, what is in a name? From the patient's viewpoint (rather than from a reimbursement viewpoint), a diagnosis legitimizes symptoms and provides a prognosis. These fac­ tors, rather than the diagnostic label itself, are important to the patient; accordingly, the direction taken by health status measurement (the impetus for which originated with social scientists, not physicians) is toward functioning and feelings, not biomedical phenomena. Patient F actors.-The first imperative in improving con­ cordance is a better understanding of the patient factors that

McBurney et al1 report on an unusual approach to measuring continuity in a “continuity clinic,” in which residents follow assigned patients, primarily for well-child care. Their method assesses the proportion of all visits made by patients who are members of the residents’ panels. In primary care practice, in contrast, continuity would be the extent to which patients see their doctor for both well- and sick-child care, which is a very different measure. Primary …

Equity in health has been defined, in terms to facilitate its assessment and achievement, as the absence of systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, geographically, or demographically (International Society for Equity in Health, 2004). Thus, the key to success in equity research and interventions is to understand those factors that influence the distribution of health in populations.

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.

The prevalence, health care expenditures, and hospitalization experiences are important considerations among elderly populations with multiple chronic conditions.A cross-sectional analysis was conducted on a nationally random sample of 1 217 103 Medicare fee-for-service beneficiaries aged 65 and older living in the United States and enrolled in both Medicare Part A and Medicare Part B during 1999. Multiple logistic regression was used to analyze the influence of age, sex, and number of types of chronic conditions on the risk of incurring inpatient hospitalizations for ambulatory care sensitive conditions and hospitalizations with preventable complications among aged Medicare beneficiaries.In 1999, 82% of aged Medicare beneficiaries had 1 or more chronic conditions, and 65% had multiple chronic conditions. Inpatient admissions for ambulatory care sensitive conditions and hospitalizations with preventable complications increased with the number of chronic conditions. For example, Medicare beneficiaries with 4 or more chronic conditions were 99 times more likely than a beneficiary without any chronic conditions to have an admission for an ambulatory care sensitive condition (95% confidence interval, 86-113). Per capita Medicare expenditures increased with the number of types of chronic conditions from $211 among beneficiaries without a chronic condition to $13 973 among beneficiaries with 4 or more types of chronic conditions.The risk of an avoidable inpatient admission or a preventable complication in an inpatient setting increases dramatically with the number of chronic conditions. Better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.

To examine those factors associated with the use of different types of ambulatory health services in a rural adolescent population.The student bodies of 2 middle schools and 2 high schools in rural areas in a mid Atlantic state (N = 1615) were surveyed using a self-administered health status and health services use instrument. Logistic regression was used to assess factors predicting receipt of (1) preventive services, (2) problem-focused services, and (3) emergency services.One third of the rural youth reported having received preventive services within the previous 3 months; 41% received problem-focused care, and 18% received emergency services. Having the same provider for both preventive and illness care was the most consistent and significant predictor of receipt for all types of ambulatory services. Of special note is the greater use of emergency services when subjects did not have a consistent provider for both preventive and illness care. Health need variables, measured across a wide range of domains, were additionally predictive, and their significance varied according to the type of services received.This study provides compelling evidence that for rural adolescents, having a regular source of care and medical need are the most important predictors of use across a variety of types of ambulatory care.