Barbara Starfield

Continuity of care: a multidisciplinary review

The concept—and reality—of continuity of care crosses disciplinary and organisational boundaries. The common definitions provided here should help healthcare providers evaluate continuity more rigorously and improve communication Patients are increasingly seen by an array of providers in a wide variety of organisations and places, raising concerns about fragmentation of care. Policy reports and charters worldwide urge a concerted effort to enhance continuity,1–3 but efforts to describe the problem or formulate solutions are complicated by the lack of consensus on the definition of continuity. To add to the confusion, other terms such as continuum of care, coordination of care, discharge planning, case management, integration of services, and seamless care are often used synonymously. This synthesis was commissioned by three Canadian health services policy and research bodies. The aim was to develop a common understanding of the concept of continuity as a basis for valid and reliable measurement of practice in different settings. We searched academic and policy literature for documents in which the principal focus was continuity of patient care or continuity. We searched electronic databases (Medline, HealthSTAR, Embase, CINAHL, Current Contents, PsychINFO, AIDSLINE, CancerLit, Cochrane Library, Dissertation abstracts, Papers1st (conferences and paper abstracts), Web of Science, WorldCat) as well as web library catalogues, peer reviewed internet sites, internet search engines, and several in-house databases. The search included documents dated from 1966 to November 2001 written in English, French, or Spanish. The reviewers (RJR, JLH, RMcK) used a data abstraction form to summarise relevant documents from every health discipline, and all reviewers read key documents. We presented the results of an initial review of 314 documents to participants of a workshop on continuity held in Vancouver in June 2001. We obtained structured feedback to a discussion paper, problem based scenarios, and expert presentations. Participants validated the common themes …

Defining Comorbidity: Implications for Understanding Health and Health Services

Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.

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 countrys 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.

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 persons 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 persons 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 states 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.

Policy relevant determinants of health: an international perspective

BACKGROUND International comparisons can provide clues to understanding some of the important policy-related determinants of health, including those related to the provision of health care services. An earlier study indicated that the strength of the primary care infrastructure of a health services system might be related to overall costs of health services. The purpose of the current research was to determine the robustness of the findings in the light of the passage of 5-10 years, the addition of two more countries, and the findings of other research on the possible importance of other determinants of country health levels. METHODS Thirteen industrialized countries, all with populations of at least 5 million, were characterized by the relative strength of their primary care infrastructure, the degree of national income inequality, and a major manifestation of a behavioral determinant of health that is amenable to policy intervention (smoking), using international data sets and national informants. Health system and primary care practice characteristics were judged according to pre-set criteria. Major indicators of health were used as dependent variables, as were health care costs. FINDINGS The stronger the primary care, the lower the costs. Countries with very weak primary care infrastructures have poorer performance on major aspects of health. Although countries that are intermediate in the strength of their primary care generally have levels of health at least as good as those with high levels of primary care, this is not the case in early life, when the impact of strong primary care is greatest. A subset of characteristics (equitable distribution of resources, publicly accountable universal financial coverage, low cost sharing, comprehensive services, and family-oriented services) distinguishes countries with overall good health from those with poor health at all ages. Neither income inequality nor smoking status accurately identified those countries with either consistently high or consistently poor performance on the health indicators. INTERPRETATION A certain level of health care expenditures may be required to achieve overall good health levels, even in the presence of strong primary care infrastructures. Very low costs may interfere with achievement of good health, particularly at older ages, although very high levels of costs may signal excessive and potentially health-compromising care. Five policy-relevant characteristics appear to be related to better population health levels. There is no consistent relationship between income inequality, smoking, and health levels as measured by various indicators of health in different age groups.

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.

The influence of patient-practitioner agreement on outcome of care

A previous study suggested that patient-practitioner agreement and follow-up in ambulatory care facilitates problem resolution as judged by patients. In this study in another medical practice, practitioner-patient agreement on what problems required follow-up was associated with greater problem resolution as judged by the practitioners regardless of the severity of the problems. In this study, patients did not judge problems mentioned only by themselves to be less improved than problems mentioned by both them and their practitioners. However, in this study more of the problems mentioned only by patients were mentioned in the note of the visit contained in the medical record. Patients expected less and reported less improvements of problems that were neither mentioned by the practitioner nor written in the medical record than was the case for problems listed both by patients and practitioners. The findings of this study confirm those of the previous study in suggesting that practitioner-patient agreement about problems is associated with greater expectations for improvement and with better outcome as perceived by patients. In addition, they indicate that practitioners also report better outcome under the same circumstances.

Comorbidity: Implications for the Importance of Primary Care in ‘Case’ Management

BACKGROUND Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients’ overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

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.

Social class gradients in health during adolescence

Study objective: To review existing data on social class gradients in adolescent health and to examine whether such gradients exist in new data concerning US adolescents. Design: Review of relevant publications and unpublished data; regression analyses using adolescent self reported health status data to determine whether there are gradients by social class, using three classes categorised by adolescent reported parental work status and education. Participants: Adolescents of ages 11–17. Main results: Findings from the literature indicate the presence of social class gradients in some but not all aspects of adolescent health. Results from new data showed social class gradients in several domains of health and in profiles of health. The likelihood of being satisfied with ones health, of being more resilient (better family involvement, better problem solving, more physical activity, better home safety), having higher school achievement, and of being in the best health profiles were significantly and progressively greater as social class rose. Moreover, the probability of being in the poorest health profile type group was progressively higher as social class declined. Conclusions: The review of existing data and the new findings support the existence of social class gradients in satisfaction with ones health, in resilience to health threats, in school achievement, and in being in the best health overall (as manifested by the health profiles composed of four major domains of health). The study had two especially notable findings: (1) the paucity of studies using the same or similar indicators, and (2) the consistent existence of social class gradients in characteristics related to subsequent health, particularly intake of nutritional foods and physical activity. The sparseness of existing data and the different aspects of health investigated in the relatively few studies underscore the need for (1) the development of conceptual models specifically focused on adolescent health and social class; (2) additional inquiry into the measurement of social class and adolescent perceptions of class; (3) inclusion of contextual variables in study design; and (4) longitudinal cohort studies to better understand the specific determinants of health during adolescence.