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Biomedical subjects

Barbara Starfield

Publications and source records attributed to Barbara Starfield.

At least 37 records · Page 2Linked to original sources
PubMed2004

The Child Report Form of the CHIP-Child Edition: reliability and validity.

BACKGROUND: There is increasing recognition of the importance of obtaining children's reports of their health, but significant challenges must be overcome to do so in a systematic, population-based manner. OBJECTIVE: The objective of this study was to present the initial tests of the Child Report Form of the Child Health and Illness Profile-Child Edition (CHIP-CE/CRF), a self-report health status instrument for children 6 to 11 years old. METHODS: Three studies iteratively evaluated revisions of the CHIP-CE/CRF in 4 geographic locations in the United States. Children (N=1708) whose families represent the low to middle socioeconomic strata and predominant U.S. racial/ethnic groups were involved. RESULTS: The final CHIP-CE/CRF includes 5 domains: Satisfaction (with self and health), Comfort (emotional and physical symptoms and limitations), Resilience (positive activities that promote health), Risk Avoidance (risky behaviors that influence future health), and Achievement (of social expectations in school and with peers). The internal consistency and test-retest reliability of the domains are good to excellent, with a definite age gradient such that younger children's responses are less reliable although still acceptable. Validity is supported through criterion and construct validity tests and structural analyses. Standard scores (mean, 50; standard deviation, 10) were established. CONCLUSIONS: Health status can be reliably and validly assessed directly from children 6 to 11 years old on the CHIP-CE/CRF. In combination with the CHIP-AE, self-reported health status can now be obtained from youth 6 to 18 years old using a consistent conceptual framework. This can greatly improve the precision and comparability of health assessments of youth, enhancing the validity of outcome research and longitudinal studies across childhood and adolescence.

Adaptation, Psychological↗
PubMed2004

Predictors of children's healthcare use: the value of child versus parental perspectives on healthcare needs.

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.

Adaptation, Psychological↗
PubMed2004

Promoting equity in health through research and understanding.

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.

Health Services Accessibility↗
PubMed2004

Comparison of private for-profit with private community-governed not-for-profit primary care services in New Zealand.

OBJECTIVE: To 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. METHODS: Observational 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. RESULTS: Compared 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. CONCLUSIONS: Community-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.

Adolescent↗
PubMed2004

A case for government ownership of primary care services in New Zealand: weighing the arguments.

Primary care services provide continuing and coordinating care, cater to most health care needs, and serve as a point of first contact with the health system. This article addresses the issue of government ownership of primary care. Ownership confers governance responsibility (ultimate control) for an organization, and accountability for its actions. Primary care organizations can be classed as government owned and operated or privately owned and operated, the latter with or without community governance. The authors address two policy questions: Does the ownership form of a primary care organization matter? What ownership frameworks should be used to guide policymaking? Arguments for and against government ownership are examined from political and economic perspectives, informed by a governance framework. Government ownership of primary care may solve problems associated with private for-profit ownership that are related to lack of control of strategic assets, lack of direct political accountability, contracting, and market failure, but it may raise potential problems of lack of responsiveness to minority and local needs and capture by interest groups. In response to the problems associated with government ownership, community-governed private nonprofits have an essential role as a vehicle for indigenous self-determination, catering for minority populations, experimenting with policy options, and providing public goods particularly for minority populations. The authors argue that private organizations that lack community governance have a lesser role.

Community Participation↗
PubMed2004

The medical home, access to care, and insurance: a review of evidence.

OBJECTIVE: To review the extent to which the literature supports the position that a medical home is important and to review the extent to which insurance is related to having a medical home. METHODS: A review of literature concerning the benefits of a medical home on effectiveness, costs, and equity (reducing disparities) was conducted. RESULTS: International and within-nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations. Although important in facilitating use overall, insurance does not guarantee a medical home. CONCLUSIONS: A medical home, with its 4 key features, provides better effectiveness as well as more efficient and more equitable care to individuals and populations. A concerted attempt to provide a means of universal financial access as well as a medical home should be of high priority for the United States.

Child↗
PubMed2003

Primary care, income inequality, and stroke mortality in the United States: a longitudinal analysis, 1985-1995.

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<0.0001). The impact of income inequality on stroke mortality was reduced in the presence of primary care (P<0.0001) but disappeared with the addition of covariates (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.

Cross-Sectional Studies↗
PubMed2003

Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study.

OBJECTIVES: The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings. RESEARCH DESIGN: Primary care practice-based study of referred and nonreferred office visits. SUBJECTS: The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states. MEASURES: Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities. RESULTS: The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages. CONCLUSION: The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.

Capitation Fee↗
PubMed2003

Validity of the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE).

OBJECTIVES: To assess the structural, convergent, discriminant, and criterion validity of the Spanish version of the Child Health and Illness Profile-Adolescent Edition (CHIP-AE) and to compare results with the U.S. version. SUBJECTS: A sample of adolescents aged 12 to 19 attending schools and representative of the school-aged population in Barcelona, Spain (n = 902). MEASURES: Exploratory factor analyses were performed, and results compared with the U.S. version. The Child Depression Inventory (CDI) and the State-Trait Anxiety Inventory (STAIC) were administered to a subgroup of adolescents to assess convergent and discriminant validity. Criterion validity was assessed by using receiver operating characteristic (ROC) curves to examine the ability of the CHIP-AE academic performance subdomain to predict school grades. RESULTS: The Spanish version has 6 defined domains with a factor structure showing minor differences from the U.S. version. Higher correlations were found between the CDI and STAIC and CHIP-AE subdomains of emotional discomfort and self-esteem (range. 0.48-0.80, P<0.01) than with scales measuring dissimilar concepts. The area under the ROC curve was 0.83 (95% confidence interval, 0.75-0.92) for the number of failed subjects (none/one or more) related to academic performance. CONCLUSIONS: The underlying theoretical model of the Spanish version of the CHIP-AE functions well in Spain, and the Spanish version has acceptable levels of convergent, discriminant, and criterion validity. Sensitivity to change and the use of the health profiles need to be assessed.

Achievement↗
PubMed2003

Primary care quality: community health center and health maintenance organization.

OBJECTIVE: This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO. METHODS: Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics. RESULTS: After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance. CONCLUSION: Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

Adult↗
PubMed2003

The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998.

OBJECTIVE: 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 SOURCES/STUDY SETTING: 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). STUDY DESIGN: Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression. DATA COLLECTION/EXTRACTION METHODS: 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. PRINCIPAL FINDINGS: 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 (p<0.05 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. CONCLUSIONS: (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.

Cross-Sectional Studies↗
PubMed2003

Income inequality and health: a critical review of the literature.

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.

Health Services Research↗
PubMed2003

The future role of health centers in improving national health.

International health rankings for the US are heavily influenced by striking racial and socioeconomic health status disparities. Current discussions of health determinants frequently relegate or entirely dismiss health care contributions despite increasing evidence of the importance of access to primary care. Health centers deliver community-based primary care to a considerable and growing proportion of the nation's most vulnerable and have produced significant health improvements, especially for women and children. Policies that disproportionately benefit those in greatest need are likely to produce the largest gains in national health. Continued expansion of the health center network to ensure primary care for those who remain underserved is both an effective and politically acceptable strategy to improve national health.

Community Health Centers↗