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Biomedical subjects

B H Starfield

Publications and source records attributed to B H Starfield.

At least 19 recordsLinked to original sources
PubMed1997

Self-sufficiency at ages 27 to 33 years: factors present between birth and 18 years that predict educational attainment among children born to inner-city families.

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

Activities of Daily Living↗
PubMed1996

Ambulatory care practice variation within a Medicaid program.

STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.

Ambulatory Care↗
PubMed1994

Primary care, financing and gatekeeping in western Europe.

Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.

Adolescent↗
PubMed1992

Johns Hopkins Ambulatory Care Groups (ACGs). A case-mix system for UR, QA and capitation adjustment.

This paper describes a new ambulatory case-mix system developed at The Johns Hopkins University and known as Ambulatory Care Groups (ACGs). ACGs categorize a person into one of 51 categories based on the diseases and conditions for which they received treatment over a period of time, such as a year. ACGs can be used to describe the "illness-burden" of a population and are up to ten times more predictive of ambulatory care resource use than age and sex alone. ACGs can be determined using a computerized "grouper" software package based on ICD-9-CM diagnosis codes and demographic information presently found in virtually all claims or encounter data systems. They were developed and tested at four HMOs and a state's Medicaid program. This paper discusses the potential application of ACGs to analysis, financing, and management of ambulatory care, specifically as it relates to utilization review (UR), quality assurance (QA) and the adjustment of capitation payment within managed care settings.

Ambulatory Care↗
PubMed1991

Development and application of a population-oriented measure of ambulatory care case-mix.

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

Adolescent↗
PubMed1989

Does a residents' continuity clinic provide primary care?

Pediatric residents are required to care for a group of children over a period of time. For many, this "continuity" experience is in a hospital outpatient department that may or may not provide primary care. We applied a measure of primary care to the Primary Care Clinic, the continuity clinic at The Johns Hopkins Hospital, Baltimore, Md, and found that it compared favorably with private pediatric practices in the Baltimore area, providing significantly more "principal care" (93% vs. 84.5% of encounters), and to the Harris Lane Home walk-in clinic, where only 51% of encounters were "principal care". The Primary Care Clinic scored higher on a primary care index, a measure of the extent to which the facility serves as a primary care source for patients, suggesting that hospital-based training can provide residents with an opportunity to provide primary care.

Child↗
PubMed1985

The regionalization of perinatal services. Summary of the evaluation of a national demonstration program.

The success of modern perinatal management techniques has led to the recommendation of the regional organization of perinatal services. This report summarizes the evaluation of a national demonstration program of such regionalization that was funded by the Robert Wood Johnson Foundation (RWJF) in 1975. In both funded regions and comparison areas, the neonatal mortality rates decreased sharply over the decade of the 1970s. This decline was linked to shifts in the hospital of delivery that indicated antepartum risk identification and transfer of management of high-risk pregnancies to tertiary centers for delivery, a change in service pattern consistent with some aspects of regionalization. The centralization of high-risk deliveries appeared so widespread that the special effect of the RWJF program could not be detected. Surveys of surviving 1-year-old infants showed that the decrease in neonatal mortality was accompanied by a decrease in selected morbidity.

Child Health Services↗
PubMed1984

Surgical decision making and operative rates.

A total of 4,687 surgeons from Canada, England, and the United States were asked to assess the need for surgical intervention in fictional case vignettes. The case histories omitted external influences, eg, all aspects of the physician-patient relationship and any socioeconomic, organizational, or demographic influences. Correlations were made between known operative rates in the three countries and the surgeon's responses to the case histories. Evidence was found to indicate there are differences in the way surgeons from the three countries treat their patients when their clinical decisions are not affected by socioeconomic, organizational, and demographic influences. However, no evidence was noted that suggested such "simple" technical decisions regarding need for surgery have a major impact in determining a country's known surgical rates. The more important factors that ultimately determine known rates of surgery seem to be derived from broad economic and social forces in any given society.

Adult↗
PubMed1983

A longitudinal study of offset in the use of nonpsychiatric services following specialized mental health care.

This study examines the use of nonpsychiatric services by mentally ill persons following the receipt of specialized mental health care, frequently referred to as the "offset effect." A total of 9,761 persons enrolled during 1975 in the Columbia Medical Plan, a prepaid group practice in Columbia, Maryland, were studied over a 5-year period. Enrollees were classified into three groups: Treated--mental disorder diagnosis in 1975 and specialized mental health care in 1975; Untreated--mental disorder diagnosis in 1975 but no specialized mental health care in that year; and Comparison--neither mental disorder diagnosis nor specialized mental health care in 1975. The nonpsychiatric utilization for these groups was compared for 1973-1977. Specialized mental health care appears to have a short-term effect on nonpsychiatric utilization by attenuating the peak in use. Mentally ill persons without specialized mental health care in 1975 also reduced their use of nonpsychiatric services in 1976-1977. The utilization changes were more likely to occur in primary care departments, rather than nonpsychiatric specialty care departments. A diagnosis of mental disorder in either 1973 or 1974 was associated with a larger offset effect.

Adolescent↗
PubMed1983

Measurement of the primary care roles of office-based physicians.

The Baltimore City Primary Care Study examined the role of the urban office-based physician in the delivery of primary care. During the course of the study, questionnaires were completed by over 90 per cent of licensed physicians in the city, and data were collected from a sample of 16,000 patients. The study developed and assessed three approaches for the measurement of primary care. An empirical method was based upon information regarding the following characteristics of each visit: first contact visit, referral visit, specialized care visit, or principal care visit. A normative method was based on an assessment of the degree to which the practice provided care that was comprehensive, longitudinal, accessible, and family-centered. The third method used physicians' judgments as to the proportion of patients for whom they maintained ongoing responsibility for general medical care. All three methods produced the same categorization of different specialties as providing either primary, intermediate, or specialty care. As a group, primary care physicians included general and family physicians, pediatricians, and general internists. General surgeons and obstetrician/gynecologists have characteristics of both primary care and specialist care. All other physician groups have characteristics of specialists. Any of these methods or a combination of methods can be used to assess the extent to which the practice of a particular physician or group of physicians provides primary care.

Humans↗
PubMed1983

Changes in infant morbidity associated with decreases in neonatal mortality.

Neonatal mortality and morbidity among infants surviving to 1 year of age in eight geographic areas have been compared to determine whether recent decreases in mortality have affected the risk of infants having congenital anomalies or developmental delay. Mortality was obtained from birth and death records in 1976 and either 1978 or 1979; morbidity through home interviews with mothers of random samples of infants and developmental observations on the children. It is concluded that the decrease in mortality was not offset by increases in children with defects. Neonatal mortality decreased by 18% in this 2- to 3-year period; risk of congenital anomalies or developmental delay (all types combined) declined by 16% among the surviving infants. The reduction in risk was concentrated in the minor congenital anomalies or developmental delay category; the proportion of children with severe or moderate congenital anomalies or developmental delay did not change. Decreases occurred at every birth weight including the very low birth weights of 1,500 g or less, a subgroup with especially high mortality and morbidity resulting from perinatal events.

Birth Weight↗
PubMed1981

Injury and its correlates among 1-year-old children. Study of children with both normal and low birth weights.

Factors associated with injury in the first year of life were examined using data on a random sample of infants in eight regions in the United States. By 1 year of age, 8.6% of the 4,989 infants surveyed had had an injury for which medical care was sought, although serious sequelae (eg, death and developmental delay) were infrequent. The data suggest that the achievement of independent mobility, eg, walking, was a major factor in the risk of injury. Other risk factors included very young mothers and isolated mothers, but not socioeconomic status, illness in the infant, or low birth weight. However, identification of small groups at very high risk is not possible, so that health professionals should be prepared to counsel all new parents early about injuries.

Birth Weight↗
PubMed1981

Parental perceptions of enuresis. A collaborative study.

Of 1,379 children 4 years of age and older who were patients in nine medical centers across the country, 346 (25.1%) were found to be enuretic. Their parents considered heavy sleeping and emotional problems as the main causes of enuresis in children; physical causes rarely were believed to be important. "Waking up the child" from sleep to urinate and "talking about the problem" were the main methods that parents used to treat enuresis. Very few used medication. Parents with a grade school level of education punish bed-wetting children at twice the rate of high school- and college-educated parents. Physicians need to be more aware that enuresis is an important problem for parents and that there are many widely held beliefs about cause and management.

Adolescent↗
PubMed1981

The association of patient-held records and completion of immunizations.

Patient-held records have been advocated as a means of increasing knowledge of an compliance with the processes of health care. The association between one type of patient-held record, the immunization record, and completion of the recommended immunizations for the first year is examined. Immunization completion rates varied by socioeconomic and medical care use variables; but, for all variables studied, completion rates were higher for those infants for whom immunization records were available than those without such records. An experimental assessment of the usefulness of patient-held immunization records as a means of improving compliance and meeting national goals for levels of immunization is suggested.

Diphtheria Toxoid↗
PubMed1980

Relevance of correlates of infant deaths for significant morbidity at 1 year of age.

This paper examines the issue of whether or not factors identified as risks for death in the first year of life also serve as risks for morbidity in surviving infants through data collected on 390,425 live births, 5,084 infant deaths, and 4,327 surviving 1-year-old children among singleton births in eight geographically defined regions in the United States. Factors which presented risks for neonatal death, such as advanced maternal age and maternal history of prior fetal loss, proved to present risks for congenital anomalies/severe developmental delay, whereas factors heavily influenced by environmental conditions, such as young maternal age and lower maternal educational attainment, were associated with higher postneonatal mortality rates and other significant illness, among both low-birth-weight and normal-birth-weight infants. The association of delivery by cesarean section with death and morbidity was also explored.

Adolescent↗
PubMed1980

Rehospitalization in the first year of life for high-risk survivors.

The first year of life is an age when morbidity and medical care use is high, and this is particularly true for low birth weight infants. Whether certain factors characterize subgroups at especially increased risk was examined for a large random sample (N = 4,989) of 1-year-old infants by using rehospitalization as the dependent variable. Overall, 9.1% of the infants had been rehospitalized, and this increased with decreasing birth weight to 38.2% of those less than or equal to 1,500 gm at birth. Low birth weight infants accounted for 6.4% of 1-year-olds, but 13.6% of those hospitalized and 20.0% of all hospital days among these infants. Factors affecting the chances of rehospitalization for low birth weight and normal birth weight infants, with and without congenital anomalies/developmental delay, were similar. Maternal hospitalization during pregnancy, prolonged postnatal stay of the infant, variables indicative of low socioeconomic status, and certain types of medical care use were associated with increased risk of hospitalization. The risk of hospitalization associated with some variables was high, but it was not possible to identify with precision a group where reduction in hospitalization would result in major decrease in overall hospital use by infants.

Analysis of Variance↗
PubMed1978

Physicians and non-physician health practitioners: the characteristics of their practices and their relationships.

Six primary care practices which utilize both physician and non-physician practitioner types were studied to measure differences between practitioner types in the care of patients. By chart review 1,369 patient-practitioner encounters were examined. Physicians identified less symptoms and signs in their patients and prescribed less non-drug therapies than did non-physicians. Likewise, at follow-up visits, physicians tended to document less follow-up of these types of problems and therapies than non-physicians. When examining the interaction between practitioners, the highest rates of follow-up of all types of problems and therapies were found when the same practitioner saw the patient at two successive visits to the same clinic. When a physician saw a patient following a previous visit to a nurse practitioner, there was a significant drop-off in the follow-up rate of problems and therapies. However, when a nurse practitioner saw the patient following a previous visit to a physician, the drop-off in follow-up rates was not as striking. These findings indicate that the skills of physician and nonphysician practitioners are potentially complementary. However, this potential is not fully exploited, particularly by physicians.

Diagnosis↗