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The purpose of this article is to review what is known about the relationship between social gradients and health in children. The article starts with a brief history of the relationship between social circumstances and health and makes the distinction between the relationship of poverty on health and the relationship between social gradients on health. Providing a summary of recent evidence on this latter relationship in various countries and in various population subgroups, the article shows that although there are social gradients in health, the magnitude of the effect varies from place to place and across different health conditions. Explanations for these differences and for demonstrated interactions between influences in different populations are sought in the possible mechanisms by which social gradients in child health affect adult health, and the pathways through which such effects might take place. The article concludes that the existence of social gradients is a societal phenomenon and that the evidence indicates that universal social programs rather than targeted social welfare have the highest likelihood of overcoming these gradients. Universal primary care-oriented health systems and their impact in reducing social gradients in health is provided as an example. An agenda for research to better understand the genesis of social gradients in health forms the final section of the article.

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

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

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

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

As of 2005, the literature on the benefits of primary care oriented health systems was consistent in showing greater effectiveness, greater efficiency, and greater equity. In the ensuing five years, nothing changed that conclusion, but there is now greater understanding of the mechanisms by which the benefits of primary care are achieved. We now know that, within certain bounds, neither the wealth of a country nor the total number of health personnel are related to health levels. What counts is the existence of key features of health policy (Primary Health Care): universal financial coverage under government control or regulation, attempts to distribute resources equitably, comprehensiveness of services, and low or no copayments for primary care services. All of these, in combination, produce better primary care: greater first contact access and use, more person-focused care over time, greater range of services available and provided when needed, and coordination of care. The evidence is no longer confined mainly to industrialized countries, as new studies show it to be the case in middle and lower income countries. The endorsements of the World Health Organization (in the form of the reports of the Commission on Social Determinants of Health and the World Health Report of 2008, as well a number of other international commissions, reflect the widespread acceptance of the importance of primary health care. Primary health care can now be measured and assessed; all innovations and enhancements in it must serve its essential features in order to be useful.

Resumen: Objetivos: Conocer cómo asumen y desempeñan los médicos de asistencia infantil en Cataluña los atributos de la atención primaria (AP) (coordinación, globalidad y longitudinalidad). Material y métodos: Estudio cualitativo basado en grupos de discusión y entrevistas individuales semiestructuradas con pediatras cuyo perfil había sido definido previamente según características sociodemográficas y de formación. Se llevaron a cabo 2 grupos de discusión (5 y 4 personas respectivamente) y 5 entrevistas individuales. Los participantes respondieron dos preguntas: ¿cómo explicaríais vuestra función como pediatras de AP? y ¿cuál es vuestra opinión sobre la relación entre los pediatras de AP y los especialistas a los que deriváis a los pacientes? Se llevó a cabo un análisis de contenido temático. Resultados: Los pediatras asumen que la AP debe ser integral y tener en cuenta el contexto del niño/a. El vínculo que se establece con las familias es una característica definitoria de su función. Detectan deficiencias en su propia formación y escaso reconocimiento social e institucional de su trabajo. La coordinación con la atención especializada y la transferencia de información entre niveles no son satisfactorias. Se identifican como factores facilitadores el conocimiento personal, la formación común y las sesiones clínicas. Conclusión: A pesar de su formación hospitalaria, los pediatras asumen los atributos de la AP. Se propone abordar los aspectos deficitarios, como la falta de formación en AP, y tener en cuenta el escaso reconocimiento institucional y social, así como las dificultades en la coordinación, para mantener un nivel de calidad elevado en la atención primaria a la población infantil. Abstract: Objectives: Primary care (PC) paediatricians are trained mainly in the hospital setting, with little contact with PC. This study aimed to find out what perceptions and experiences they have on the attributes of PC (first contact, comprehensiveness and continuity of care) that are assumed and performed by PC paediatricians. Material and methods: A qualitative study was performed based on focus groups and semi-structured individual interviews with paediatricians with pre-defined sociodemographic and speciality training characteristics. Two focus groups (5 and 4 people each) and 5 interviews were made. Participants responded to two questions: how would you explain your function as a primary care paediatrician? and what is your opinion on the relationship between primary care paediatricians and the specialists to whom your patients are referred? The conversations of the groups and interviews were recorded and transcribed, and a content analysis was performed. Results: Paediatricians assume that PC must be comprehensive, and take into account the context of the child. Paediatricians declare a lack in their training and poor social and institutional recognition. Coordination with specialists and the transfer of information are not satisfactory. Helpful factors are personal knowledge, the shared training and the face-to-face clinical sessions. Conclusion: Despite their hospital-based training, paediatricians assume the attributes of PC. Difficulties in performing their function include poor adaptation of their training to PC, and little institutional and social recognition. Coordination with specialists is not satisfactory. Approaching these difficulties can help maintaining a high quality level in the care of the paediatric population.

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

A consensus exists that health systems undergirded by primary health care principles achieve better health and greater equity in health than systems with a specialty care orientation. Primary Health Care (as a set of principles and policies) and Primary Care (as a set of clinical functions) are now sufficiently well understood to define their components and facilitate measurement and evaluation. A key component is recognition, by the health system and by clinical practitioners, of the health related needs and problems of populations and patients, respectively. While “patient-centered” is touted as an important goal, there is little agreement on what it is, how it should be achieved, or how it is related to population health services. This paper reviews evidence for the benefits of primary care-oriented health systems and shows how “patient-focus” and “problem recognition” are key to successful primary health care. I argue for focusing on meeting peoples' needs, as expressed by them, rather than by professionals, in their own terms. Several high-profile attempts to improve services appear to run counter to this principle, and deserve attention by those who would frame the health services reform debate only as an issue of access to disease-oriented technical quality of care.

Foreword The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org. Robust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, ther...

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

Despite an early start in the transformation of its health system toward a primary care infrastructure, Canada has not kept pace in the production of knowledge that is needed to support forward momentum. Having achieved the three key system features needed for primary care practice (attempted distribution of resources equitably; government control or heavy regulation of insurance; and low or no copayments), Canada now needs to take bold steps to address at least two interrelated challenges: (1) to shift from a disease orientation to a population orientation toward multi-morbidity and (2) to better understand the delineation of the relative roles of primary care physicians and specialists. The Canadian commitment to primary care research has been very weak. Its strengthening would help Canada to move ahead and could contribute greatly to the advancement of primary care as a worldwide imperative of the 21st century.

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

The NHS Plan signalled the creation of GPs with special interests (GPwSIs) in the UK. The role of a GPwSI involves the acquisition of knowledge and skills that enable GPs to dedicate a portion of their time to performing the role of consultants to their colleagues within the ambit of general practice, and with respect to specific health problems encountered. The objectives behind the introduction of GPwSIs are to improve the patient's access to specialist care, to cut waiting-list times, and to save on referral costs, (and as a consequence to increase the prestige of the GPs involved). However, the reality may not meet these expectations. Before accepting the proposition for universal implementation of GPwSIs empirical evidence is required to demonstrate that overall health is improved (of patients as well as the population); patients, especially patients of doctors working alone or in small groups (specifically in rural areas) are not disadvantaged; referral is improved and made more appropriate to the requirements of patients and their health problems; real prestige is generated, not only among GPs and students, but also among patients; biological views typical of the specialist are not promoted; and a brake is not applied to other alternatives in, or the reorganisation of, primary care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970–1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates—even while controlling for GDP per capita. Health system variables—in particular the method of healthcare financing and the supply of physicians—significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.

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

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

To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n = 504).Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

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

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

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

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

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

In this issue of JECH, authors from both the People’s Health Movement 1 and WHO 2 agree that primary healthcare makes a considerable contribution to reducing the adverse impact of social inequalities on health. That is, primary healthcare is a ‘health equity-producing’ social policy. Both groups of authors agree that health systems do not exist in isolation from other social systems. Both provide examples of how the market orientation of neo-liberal globalisation has worked against improvements in general and equity in health specifically. The role of world trade agreements in compromising nutritional status of socially disadvantaged populations provides a powerful case for the importance of inter-sectoral approaches in health policy activities. Both papers speak of ‘primary health care’ rather than of ‘primary care’. The distinction between the two is at the heart of achieving greater equity in health through societal actions. Both clinical practices and system policies need consideration. 3 The literature on ‘primary care’ is largely clinical, having to do with the behaviour of health services professionals and their interactions with people and, increasingly, the subpopulations for whom they provide services. Within the last two decades there has been increasing clarity about which ‘behaviours’ are most important to adequacy of primary care: first contact accessibility and use, identification with a regular source of care that is person (rather than disease) focused care over time, comprehensiveness of services available and provided, and coordination (when care from other places is required). These characteristics, all amenable to assessment in reliable and valid ways, are now so well-known that tools for their assessment are rapidly being adopted in many different places around the world. 4 International comparisons demonstrate that good clinical primary care depends on good primary healthcaredthat is, on specific health system policies for population. Critical among these policies are attempts to distribute resources equitablydthat is, according to need; ‘progressive’ (as distinguished from ‘regressive’) financing under government control or regulation; low or no cost sharing for primary care services; and breadth of services available (comprehensiveness) within the primary care sector. 35 Each of these policy characteristics reflects more general system characteristics: focus on distribution of health characteristics in the populationdthat is, an equity focus rather than just on average levels; progressivity of financing of social services in general; and consideration of population needs rather than demands (which favour the more powerful rather than the disenfranchised). That is, societies that are more equitable tend to be more equitable in many regards, 6 because progressive governments generally promote more progressive policies across a range of social sectors. Primary healthcare-oriented health systems have been shown to be generally more effective in achieving better health (particularly at young ages) at lower costs than is the case for systems more oriented to disease management and specialty care. It is not often recognised that they have more equitable distributions of health as well. Even in the USA, one of the most inequitable societies in the industrialised world, better primary care resources preferentially improve health more in socially disadvantaged populations than in the majority population. 7 A comparison of age adjusted survival from breast cancer in Canada (which has a health system more oriented towards primary care than in the USA) showed a strong socioeconomic gradient in survival from breast cancer in the USA but not in Canada and demonstrated that the survival advantage in cancer is present in low-income areas only and that it is less in women over the age of

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