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Biomedical subjects

Barbara Starfield

Publications and source records attributed to Barbara Starfield.

62 records · Page 4Linked to original sources
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U.S. child health: what's amiss, and what should be done about it?

This paper addresses the state of health of U.S. children and finds it to be poorer in virtually every way than that of children in other countries. It explores several possible explanations, including population heterogeneity, social (including income) inequality, and inadequacy of the health services system. The latter explanation is found to relate to the underdevelopment of U.S. primary care. In light of the position taken by the World Health Organization regarding the importance of primary care, adopting the recommendations of a new National Research Council/Institute of Medicine report and some changes in health policy could help improve the health of American children.

Adolescent↗
PubMedDate not supplied

The effects of specialist supply on populations' health: assessing the evidence.

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 previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Evidence-Based Medicine↗
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[Primary health care and responsibilities of public health in 6 countries of Europe and North America: a pilot study].

BACKGROUND: Rapidly occurring changes within the health care systems are creating an opportunity to re-orient the relationships between their different sectors. In order to know the locus of responsibility for various types of preventive activities, we undertook an inquiry on eight areas in six countries from Europe and North America. METHODS: An inquiry among experts based on a matrix which arrayed the type of preventive health services against the target population. Eight clinical conditions were identified (childhood immunizations; adult influenza vaccination; mammography screening, tuberculosis screening, hypertension screening. PKU screening, HIV screening, and osteoporosis testing) trying to know their target population and the locus of responsibility for setting of policy, level to contact individuals for testing, follow-up of people with abnormal tests and maintenance of their medical records. RESULTS: This pilot study showed very little results coincidence either within the eight surveyed areas or across them. There was no regular pattern for the preventive activities studied among the different countries, neither according to the type of health system, nor to the primary health care orientation of the different systems. CONCLUSIONS: There was a limited consensus in the activities studied concerning the best mode of doing public health interventions for personal health services.

Canada↗
PubMedDate not supplied

The relationship between primary care, income inequality, and mortality in US States, 1980-1995.

OBJECTIVES: This study tests the robustness of the relationships between primary care, income inequality, and population health by (1) assessing the relationship during 4 time periods-1980, 1985, 1990 and 1995; (2) examining the independent effect of components of the primary care physician supply; (3) using 2 different measures of income inequality (Robin Hood index and Gini coefficient); and (4) testing the robustness of the association by using 5-year time-lagged independent variables. DATA SOURCES/STUDY SETTING: Data are derived from the Compressed Mortality Files, the US Department of Commerce and the Census Bureau, the National Center for Health Statistics, the Centers for Disease Control and Prevention, and the American Medical Association Physician Master File. The unit of analysis was the 50 US states over a 15-year period. STUDY DESIGN: Ecological, cross-sectional design for 4 selected years (1980, 1985, 1990, 1995), and incorporating 5-year time-lagged independent variables. The main outcome measure is age-standardized, all-cause mortality per 100,000 population in all 50 US states in all 4 time periods. DATA COLLECTION/EXTRACTION METHODS: The study used secondary data from publicly available data sets. The CDC WONDER/PC software was used to obtain mortality data and directly standardize them for age to the 1980 US population. Data used to calculate the income inequality measure came from the US census population and housing summary tapes for the years 1980 to 1995. Counts of the number of households that fell into each income interval along with the total aggregate income and the median household income were obtained for each state. The Gini coefficient for each state was calculated using software developed for this purpose. RESULTS: In weighted multivariate regressions, both contemporaneous and time-lagged income inequality measures (Gini coefficient, Robin Hood Index) were significantly associated with all-cause mortality (P <.05 for both measures for all time periods). Contemporaneous and time-lagged primary care physician-to-population ratios were significantly associated with lower all-cause mortality (P <.05 for all 4 time periods), whereas specialty care measures were associated with higher mortality (P <.05 for all time periods, except 1990, where P <.1). Among primary care subspecialties, only family medicine was consistently associated with lower mortality (P <.01 for all time periods). CONCLUSIONS: Enhancing primary care, particularly family medicine, even in states with high levels of income inequality, could lead to lower all-cause mortality in those states.

Cross-Sectional Studies↗
PubMedDate not supplied

Variability in physician referral decisions.

BACKGROUND: Because it is possible that part of the variability in frequency of interventions and even in outcomes results from the variability in referral patterns of primary care physicians, our objectives were to examine primary care physician decision making about referrals for several common adult and childhood conditions. METHODS: One hundred thirty-six family physicians in 80 office-based practices recorded reasons for referral to the most common types of specialists and the expectation of the specialist for conditions with at least seven referrals to each specialist. RESULTS: By far the most referrals were expected to be short-term (< 12 months); for more than 50%, the referrals were for consultation only (rather than direct intervention). For most of the 10 types of conditions, there were no apparent differences in reason for or expectation of the referral that would explain the choice of different types of specialists for referral. Expectations for shared care were generally more common in referrals to nonphysicians than to physicians. CONCLUSIONS: This study revealed unexplained variability among family physicians in the specialists to whom patients are referred for specific conditions. Why some patients with the same condition are referred to surgeons and others to medical specialists is unclear, at least in the context of expectations for referral as being long-term vs short-term or consultative vs referral for definitive management. The impact of this variability on costs and outcome could be considerable and deserves more intensive study.

Decision Making↗