Access--perceived or real, and to what?
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Health Services Accessibility↗
Biomedical subjects
B Starfield
Publications and source records attributed to B Starfield.
The adolescent child health and illness profile. A population-based measure of health.
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.
Adolescent↗
Health systems' effects on health status--financing vs the organization of services.
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Australia↗
Hospitalizations of children and access to primary care: a cross-national comparison.
In the United States, hospital admissions for conditions sensitive to primary care are related to socioeconomic characteristics. The authors compare the prevalence of avoidable hospital admissions and their relationship to socio-economic and primary care characteristics in Spain and the United States. A case-control analysis of the relationship between avoidable hospitalizations and socioeconomic characteristics (illiteracy, unemployment, income) and primary care characteristics (type of physician and facilities for primary care) of children's area of residence was conducted in Spain. Bivariate statistical tests and conditional logistic regression were used to test the strength of the association among the variables, and to calculate the probability of being admitted to hospital for treatment of an ambulatory care sensitive (ACS) condition. Neither socioeconomic nor primary care characteristics affected this probability, and the rate of admission for ACS conditions was lower in Spain than in the United States. The provision of universal financial access to care and the availability of a consistent and accountable primary care provider are associated with lower hospitalization rates for conditions that are preventable with good primary care.
Ambulatory Care↗
Career differences between primary care and traditional trainees in internal medicine and pediatrics.
OBJECTIVE: To assess the relation of Primary Care Residency Training to career choice, board certification, and practice location of internists and pediatricians. DESIGN: Cohort study with up to 8 years of follow-up. SETTING: The United States. PARTICIPANTS: The 17,933 residents trained in all internal medicine (13,750) and pediatrics (4,183) residency programs between 1977 and 1982 were studied using information from the National Resident Matching Program, the AMA Physician Masterfile, the Area Resource File, and a telephone survey. MEASUREMENTS: Career choice, board certification, and practice location were studied in relation to five explanatory variables: type of residency (primary care or traditional track), gender, year of medical school graduation, educational orientation of the teaching hospital, and medical school prestige. MAIN RESULTS: Graduates of primary care residency training programs chose careers in generalist primary care significantly more often than did graduates of traditional tracks in both internal medicine (72% compared with 54%) and pediatrics (88% and 81%, respectively; P less than 0.001 for both values). Board certification rates in internal medicine were statistically higher for graduates of primary care training programs (80%) than for graduates of traditional programs (76%, P = 0.002) but were not statistically significant for both groups of pediatric graduates. Graduates of primary care programs in pediatrics and internal medicine practiced in medically less served communities more often than did graduates of traditional programs. CONCLUSION: Graduates of primary care residency training programs in internal medicine and pediatrics differ from graduates of traditional residency programs in career choices, board certification rates, and practice locations.
Career Choice↗
Subspecialization within pediatric practice: a broader spectrum.
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 Physician 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 a 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 subspecialty 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 subspecialty 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.
Adult↗
Race, family income, and low birth weight.
The relations among race, family income, and low birth weight were examined using information obtained from the National Longitudinal Survey of Youth, which conducted yearly interviews with a nationally representative sample of young women identified in the late 1970s. Data were available for these women and their offspring from 1979 through 1988. Maternal education, maternal age, age/parity risk, marital status, and smoking during pregnancy served as covariates in cross-sectional and longitudinal analyses. The risk of low birth weight among births to black women and white women who were poor was at similarly high levels regardless of whether poverty was determined prior to study entrance or during the study period. Longitudinal analyses showed an exceptionally large increase in risk of low birth weight among children born to women whose prior pregnancy ended in a low-birth-weight infant. These two findings emphasize the importance of factors antecedent to the pregnancy in the genesis of low birth weight.
Adolescent↗
Childhood morbidity: comparisons, clusters, and trends.
Standard mortality and morbidity data are important but incomplete descriptors of child health. Simple prevalences of individual conditions fail to capture fully the nature of ill health in childhood. More enlightening are comparative prevalences: cross-nationally, in different population subgroups, or as trends over time. A longitudinal perspective that provides information on high-risk states and that the nature of their impact on various aspects of health over time adds another dimension to an understanding of child health needs. A better understanding of the meaning of "health problems" in children and documentation of their distribution in the population will help to tailor better the organization and delivery of preventive, curative, and restorative child health services to child health needs.
Adolescent↗
Ambulatory care groups: a categorization of diagnoses for research and management.
This article describes a case-mix measure for application in ambulatory populations. The method is based primarily on categorization of diagnoses according to their likelihood of persistence. Fifty-one combinations (the ambulatory care groups or ACGs) result from applying multivariate techniques to maximize variance explained in use of services and ambulatory care charges. The method is tested in four different HMOs and a large Medicaid population. The percentage of the population in each of the 51 categories is similar across the HMOs; the Medicaid population has higher burdens of morbidity as measured by more numerous types of diagnoses. Mean visit rates for individuals within each of the 51 morbidity categories are generally similar across the five facilities, but these visit rates vary markedly from one category to another, even within groupings that are similar in the number of types of diagnoses within them. Visit rates for individuals who stay in the same ACG were similar from one year to the next. The ACG system is found useful in predicting both concurrent and subsequent ambulatory care use and charges as well as subsequent morbidity. It provides a way to specify case mix in enrolled populations for research as well as administration and reimbursement for ambulatory care.
Adolescent↗
Social environment and vulnerability of low birth weight children: a social-epidemiological perspective.
This study examined the impact of low birth weight on children's health and assessed the influence of the social environment on various aspects of health in low birth weight and normal birth weight children. Data on 8661 children aged 2 through 11 from the 1981 Child Health Supplement of the National Health Interview Survey provided strong evidence for two major conclusions: (1) Low birth weight children in high-risk social environments are at increased for poor health outcomes compared with comparable normal birth weight children. This vulnerability was found across all age groups, suggesting that the effects of low birth weight are long-lasting. The poor health outcomes for low birth weight children in high-risk social environments were found for all seven aspects of child health status studied: excessive bed days, restricted-activity days, and school-loss days; school failure, low school-ranking, behavior problems, and maternal perception of child health status as fair/poor. (2) The mechanism of risk was complex and differed by birth weight group. Whereas certain combinations of individual risk factors protected normal birth weight children from several adverse outcomes, none for low birth weight children were identified. However, low birth weight children in low- or moderate-risk social environments were not at greater risk for poor outcomes compared with comparable normal birth weight children. This study underscores the importance of a healthy social environment for children who are already at high risk for poor health outcomes by virtue of being low birth weight.
Age Factors↗
Structured encounter form: the impact on provider performance and recording of well-child care.
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.
Child↗
Health care use by children receiving mental health services.
Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.
Child↗
Recognition of information and coordination of ambulatory care by medical residents.
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Ambulatory Care↗
Child health care and social factors: poverty, class, race.
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Child↗
Poverty, race, and hospitalization for childhood asthma.
This study uses Maryland hospital discharge data for the period 1979-82 to determine whether Black children are more likely to be hospitalized for asthma and whether this difference persists after adjustment for poverty. The average annual asthma discharge rate was 1.95/1000 children aged 1-19; 3.75/1000 for Black children, and 1.25/1000 for White. Medicaid-enrolled children of both races had increased discharge rates for asthma compared to those whose care was paid for by other sources: 5.68/1000 vs 2.99/1000 for Blacks, and 3.10/1000 vs 1.11/1000 for Whites. When ecologic analyses were performed, populations of Black and White children had nearly equal asthma discharge rates after adjustment for poverty. The statewide adjusted rate was 2.70/1000 (95% CL = 1.93, 3.78) for Black children and 2.10/1000 (1.66, 2.66) for White children. Among Maryland counties and health planning districts, variation in asthma discharge rates was not associated with the supply of hospital beds or the population to primary-care physician ratio. We conclude that Black children are at increased risk of hospitalization for asthma, but that some or all of this increase is related to poverty rather than to race.
Adolescent↗
Morbidity and use of ambulatory care services among poor and nonpoor children.
Using data from the Child Health Supplement to the 1981 National Health Interview Survey, illness and use of physician services are compared for children under 18 years old in three family income groups. The results indicate that although annual prevalence of many health problems does not differ greatly by income level, disability as measured by bed days is greater among low income children. A substantial minority of children from all socioeconomic levels are afflicted by multiple health problems. The impact of multiple conditions, as measured by days spent ill in bed, appears much greater for children from low income families. Use of physician services was found to be similar for children of all socioeconomic levels when no significant health problems were present, but low income children with health problems used fewer physician visits on an adjusted basis than their higher income counterparts.
Ambulatory Care↗
Lessons learned from the access survey.
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Health Services Accessibility↗
Family health. Utilization and effects of family membership.
The purpose of this study was to determine the extent to which members of families have similar and interrelated health behavior. Utilization and morbidity data from more than 80,000 ambulatory visits by 693 families enrolled in a prepaid health plan for 6 consecutive years were examined using family membership as the major unit of analysis. Family members were found to resemble one another in their rates of use of services (r = 0.44; P less than 0.001). Parental influence on children's utilization is significant, mothers generally being two to three times more powerful than fathers in this regard. Apart from family size, structural characteristics of families contribute little to family health behavior. Family membership explains nearly one third of the variance of individual utilization even after family size and age and sex of family members are considered. A small proportion of families (5%) accounts for a disproportionately large share (12.3%) of health care utilization. Intrafamilial patterns of morbidity were apparent for several major groupings of diagnoses, most notably for acute health problems. Intrafamilial correlations were greatest among high-utilizing families. Families establish patterns of health behavior that are stable over time and therefore may be amenable to selective interventions. We conclude that health care planning, whether for service delivery or health education intervention, should consider family health data as an important information source.
Adult↗