Search PubMed⌕ Search

Biomedical subjects

B Starfield

Publications and source records attributed to B Starfield.

At least 91 records · Page 5Linked to original sources
PubMed1994

Costs vs quality in different types of primary care settings.

OBJECTIVE: To determine the relationship between efficiency in use of resources and quality of care provided by physicians serving as the usual source of care for patients in a state Medicaid program. DESIGN: Retrospective quality-of-care review of 2024 outpatient medical records of 135 providers sampled from system-wide Medicaid claims data in Maryland. SUBJECTS: Providers in three types of practice settings (hospital outpatient clinic, community health center, and physician's office) were stratified into three case mix-adjusted resource use groups (high, medium, and low). A sample of patients with the diagnoses of diabetes, hypertension, asthma, well-child care, or otitis media were identified from Medicaid claims forms from visits during 1988. Case mix was controlled by the application of the ambulatory care groups, a method that characterizes populations according to their burden of morbidity. MAIN OUTCOME MEASURES: Nurses from the local peer review organization audited medical records using explicit criteria for quality of care in several categories: evidence of impaired access, evidence of compromised technical quality, evidence of inappropriate care, outcome of care, and several generic indicators of quality. Well-adult care was assessed for patients with the adult diagnoses. RESULTS: Although there were some systematic differences by type of facility in some aspects of quality of care (more access problems for patients in hospital clinics and more technical quality problems for patients in office-based practice), there were no consistent differences in quality of care overall for patients in different types of settings and no consistent relationships between cost-efficiency and quality of care. However, patients in medium-cost community health centers had the best or second best scores for most of the 21 comparisons of type of quality assessed. CONCLUSIONS: Quality of care provided for common conditions in primary care is not associated with costs generated by providers. Policies directed toward the choice of low-cost vs high-cost providers will not necessarily lead to a deterioration in the quality of care. States can both improve quality and lower costs by consistent monitoring of programs over time. The finding of generally higher quality of care for patients in medium-cost community health centers deserves further study.

Adult↗
PubMed1994

Current approaches to measuring health outcomes in pediatric research.

Because improving health is the ultimate goal of a health care system, the measurement of health outcomes in research is a logical and important goal for the evaluation of the impact of health services. Although health can be defined in various ways, here we employ a conceptualization that has several domains including longevity, disease, comfort, perceived well being, activity, achievement, and resilience. Given that health is such a broad concept, the difficult task for outcomes research is to provide the means of measuring it. As this brief summary of current work indicates, a number of approaches have been used in recent pediatric studies. Most focus on a small subset of health concerns. However, some studies have attempted to broaden the assessment of health outcome either by using multiple health measures or developing multidimensional instruments for measuring health. Care must be taken in evaluating the usefulness of any of the instruments until sufficient data are obtained as to their reliability and validity. Further work in this area is needed, particularly with regards to multidimensional approaches, which are beginning to provide a more sensitive and comprehensive means of assessing the impact of health services.

Activities of Daily Living↗
PubMed1994

Health care reform: the case for a primary care imperative.

One of the major goals of health reform is assuring financial access to a basic benefits package for all U.S. citizens, while maintaining better health at a contained rate of growth in costs. In questioning the ability of the Clinton Health Security Act to achieve this goal, the article presents a rationale for the consideration of those aspects of organizational reform that are necessary to achieve a primary care orientation that would meet such a goal. The author cautions that reform proposals that focus primarily on the financing of services are unlikely to influence the organizational reorientation from a specialty focus to a primary care imperative.

Evaluation Studies as Topic↗
PubMed1994

Primary care. Participants or gatekeepers?

Health systems that have a strong orientation toward primary care achieve lower overall costs, better satisfaction of their populations, and better health. The role of specialists in such systems is to provide consultative services on a short-term basis (secondary care) or long-term services for rare or complicated problems (tertiary care). Among both primary-care and specialist physicians, opinions vary considerably as to the specific tasks that are appropriate in primary and specialist care. Medical education has not proved an adequate basis for judging either the relative appropriateness of care by primary-care physicians and specialists or criteria for referral. Recent studies indicate that conventional wisdom concerning the nature and treatment of disease that is derived from research in tertiary medical centers is contradicted by collaborative practice-based studies in primary care. Better collaboration between primary-care physicians and specialists both in research and in the design of services will be the key to more informed decisions about improvement in the care of patients with diabetes and other important and common health-care problems.

Adolescent↗
PubMed1993

Child health and the social environment of white and black children.

Both poverty and other factors associated with race are related to child health. However, the mechanisms of these relationships have not been adequately specified. The purpose of this study was to explore the relationship of the social environment to child health status in black and white children and further, to explore whether the patterns of the effects of social class were different by race. This study provides further evidence that the social environment is strongly associated with child health status. Several risk factors are similar for both white and black children: mothers who view their own health as fair or poor are much more likely to rate their children in poor health. The presence of childhood chronic medical conditions is independently associated with poor health status regardless of race. However, the relative importance of several social risks for poor health status differs between white and black children. Specifically, while low family income is a consistent risk factor for poor health among white children, low income alone is not a risk factor for black children. Among black children, other social risks that are associated with poverty, such as low maternal education and a mother's perception of her own health as poor, increased the risk of poorer health in the child.

Black or African American↗
PubMed1993

Choices of training programs and career paths by women in internal medicine.

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).

Career Choice↗
PubMed1993

Primary care.

Explore the source record for details and available documents.

Data Collection↗
PubMed1993

Determinants of children's health care use: an investigation of psychosocial factors.

Factors related to the amount of health care used by 5- to 11-year-old children in a health maintenance organization (HMO) were investigated using a comprehensive multivariate model that assessed the contribution of child health need, mental health, and social functioning; maternal mental health, social support and health care utilization; and family functioning and life events. Mothers reported on the 450 participating children. Health care visits for a two-year retrospective period were obtained from the computerized encounter system. Child health need and maternal patterns of health care use were powerful predictors of the overall amount of health care used, and these factors discriminated high users from low users of care. Family conflict was associated with a higher volume of care, while children's depressive symptoms and non-white race were related to lower use. Maternal social support, mental health, and life events were not predictive of use in either full multivariate model. Enabling factors were held relatively constant by participation of all families in a prepaid HMO. The multiple regression model explained 33% of the variance in use, slightly more than in previous studies of children's health care use. When included in a comprehensive analysis, child and family psychosocial characteristics help to explain children's health care use beyond what is possible using simple health and illness variables. The implications of these findings in the development of further research and to the practice of routine pediatric care are discussed.

Adult↗
PubMed1993

The promise of HMOs: primary care, prevention, research and education.

The contributions of HMOs to research and education are important in the generation of knowledge for policy development and for training physicians to meet the needs of populations. While prepaid group practices that were the prototypical HMOs added important new information about the organization and delivery of health services, the new generation of managed care organizations has not been involved in either research or teaching. Issues that are particularly amenable to research in HMOs include the appropriate balance between primary care providers and specialists, criteria for referral from primary care to specialty services, the contributions of preventive care to health, and the testing of alternative strategies to achieve the four important characteristics of primary care practice. HMOs could also make important contributions to medical education by exposing students and residents to quality of care assessments and to practice-based research, as well as to the special challenges and rewards of population-based medical care.

Health Care Reform↗
PubMed1993

Adolescent health status measurement: development of the Child Health and Illness Profile.

This report describes the early stages in the development and testing of an instrument, known as the CHIP (Child Health and Illness Profile), for assessing the health of individuals aged 11 through 17. The purpose of the instrument is to assess health in epidemiologic surveys, to determine the existence of systematic differences in health in subpopulations (including the socioeconomically disadvantaged), and to provide a basis for assessing the impact of changes in health services or health policies. An instrument consisting of six domains with 25 subdomains was developed based on the literature, the involvement of focus groups and expert panels, and pretesting in four groups of teenagers known to differ in their health. The results of work with panels of experts suggest that the instrument has content validity. Most domains and subdomains had acceptable reliability as measured by alpha coefficients. Differences in the scores of individuals in the four groups were in the predicted directions, suggesting that the instrument also has construct validity. Additional research is under way to establish other aspects of validity as well as reliability in school populations of adolescents as well as specific clinical settings.

Activities of Daily Living↗
PubMed1992

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↗
PubMed1992

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1991

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↗
PubMed1990

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↗