Christopher B. Forrest

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.

Elementary school-aged children's reports of their health: A cognitive interviewing study

There are no standard methods for assessing the quality of young childrens perceptions of their health and well-being and their ability to comprehend the tasks involved in reporting their health. This research involved three cross-sectional studies using cognitive interviews of 5–11-year-old children (N = 114) to determine their ability to respond to various presentations of pictorially illustrated questions about their health. The samples had a predominance of children in the 5–7-year-old range and families of lower and middle socio-economic status. The research questions in Study 1 involved childrens ability to convert their health experiences into scaled responses and relate them to illustrated items (n = 35); Study 2 focused on the type of response format most effectively used by children (n = 19); and Study 3 involved testing childrens understanding of health-related terms and use of a specific recall period (n = 60). The results of Study 1 showed that children identified with the cartoon drawing of a child depicted in the illustrated items, typically responding that the child was at or near their own age and of the same gender, with no differences related to race. Study 2 results indicated that children responded effectively to circles of graduated sizes to indicate their response and preferred them to same-size circles or a visual analogue scale. Tests of three-, four-, and five-point response formats demonstrated that children could use them all without confusion. In Study 3, expected age-related differences in understanding were obtained. In fact, the 5-year-old children were unable to understand a sufficient number of items to adequately describe their health. Virtually all children 8 years of age and older were able to fully understand the key terms and presentation of items, used the full five-point range of response options, and accurately used a 4-week recall period. Six- and seven-year-olds were more likely than older children to use only the extreme and middle responses on a five-point scale. No pattern of gender differences in understanding or in use of response options was found. We conclude that children as young as eight are able to report on all aspects of their health experiences and can use a five-point response format. Children aged 6–7 had difficulty with some health-related terms and tended to use extreme responses, but they understood the basic task requirements and were able to report on their health experiences. These results provide the guidance needed to develop and test a pediatric health status questionnaire for children 6–11 years old.

The Parent Report Form of the Chip–child Edition: Reliability and Validity

BackgroundValid, comprehensive instruments to describe, monitor, and evaluate health from childhood through adolescence are almost nonexistent, but are critical for health resource planning, evaluation of policy, preventive, and clinical interventions, and understanding trajectories of health during this important period of life. ObjectivesThe objectives of this study were to describe the development, testing, and final versions of the Parent Report Form of the Child Health and Illness Profile–Child Edition (CHIP-CE/PRF), designed to measure the health of children 6 to 11 years old from the caregiver perspective. MethodsParents (N = 1049) completed a version of the CHIP-CE/PRF in 4 locations in the United States, either in clinic waiting rooms or their homes. They differed in race/ethnicity, socioeconomic level, and native language. ResultsThe Parent CHIP-CE is feasible; parents with a 5th-grade reading level complete the 76-item PRF in 20 minutes. Its domains (Satisfaction, Comfort, Risk Avoidance, Resilience, and Achievement) measure structurally distinct, interrelated aspects of health. Domain reliability is high: internal consistency = 0.79–0.88; retest reliability (ICC) = 0.71–0.85. Validity is supported. The scale scores are sensitive to predicted age, gender, and socioeconomic status differences in health. ConclusionThe CHIP–Child Edition/Parent Report Form is a psychometrically sound, conceptually based measure of child health that works well in diverse populations. It produces scores that parallel those of children on the CHIP-CE/CRF and adolescents on the CHIP-AE and allows health to be consistently assessed from childhood through adolescence. It should meet many needs for describing, monitoring, and understanding child health and evaluating outcomes of interventions.

Association of Antibiotics in Infancy With Early Childhood Obesity

IMPORTANCE Obesity in children and adults is associated with significant health burdens, making prevention a public health imperative. Infancy may be a critical period when environmental factors exert a lasting effect on the risk for obesity; identifying modifiable factors may help to reduce this risk. OBJECTIVE To assess the impact of antibiotics prescribed in infancy (ages 0-23 months) on obesity in early childhood (ages 24-59 months). DESIGN, SETTING, AND PARTICIPANTS We conducted a cohort study spanning 2001-2013 using electronic health records. Cox proportional hazard models were used to adjust for demographic, practice, and clinical covariates. The study spanned a network of primary care practices affiliated with the Childrens Hospital of Philadelphia including both teaching clinics and private practices in urban Philadelphia, Pennsylvania, and the surrounding region. All children with annual visits at ages 0 to 23 months, as well 1 or more visits at ages 24 to 59 months, were enrolled. The cohort comprised 64,580 children. EXPOSURES Treatment episodes for prescribed antibiotics were ascertained up to 23 months of age. MAIN OUTCOMES AND MEASURES Obesity outcomes were determined directly from anthropometric measurements using National Health and Nutrition Examination Survey 2000 body mass index norms. RESULTS Sixty-nine percent of children were exposed to antibiotics before age 24 months, with a mean (SD) of 2.3 (1.5) episodes per child. Cumulative exposure to antibiotics was associated with later obesity (rate ratio [RR], 1.11; 95% CI, 1.02-1.21 for ≥ 4 episodes); this effect was stronger for broad-spectrum antibiotics (RR, 1.16; 95% CI, 1.06-1.29). Early exposure to broad-spectrum antibiotics was also associated with obesity (RR, 1.11; 95% CI, 1.03-1.19 at 0-5 months of age and RR, 1.09; 95% CI, 1.04-1.14 at 6-11 months of age) but narrow-spectrum drugs were not at any age or frequency. Steroid use, male sex, urban practice, public insurance, Hispanic ethnicity, and diagnosed asthma or wheezing were also predictors of obesity; common infectious diagnoses and antireflux medications were not. CONCLUSIONS AND RELEVANCE Repeated exposure to broad-spectrum antibiotics at ages 0 to 23 months is associated with early childhood obesity. Because common childhood infections were the most frequent diagnoses co-occurring with broad-spectrum antibiotic prescription, narrowing antibiotic selection is potentially a modifiable risk factor for childhood obesity.

Adherence of Low-income Women to Cancer Screening Recommendations

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women’s adherence to cancer screening recommendations.

Entry into primary care and continuity: the effects of access.

OBJECTIVES This study examined the relationship between access and use of primary care physicians as sources of first contact and continuity with the medical system. METHODS Data from the 1987 National Medical expenditure Survey were used to examine the effects of access on use of primary care physicians as sources of first contact for new episodes of care (by logistic regression) and as sources of continuity for all ambulatory visits (by multi-variate linear regression). RESULTS No after-hours care, longer office waits, and longer travel times reduced the chances of a first-contact visit with a primary care physician for acute health problems. Longer appointment waits, no insurance, and no after-hours care were associated with lower levels of continuity. Generalists provided more first-contact care than specialists acting as primary care physicians, largely because of their more accessible practices. CONCLUSIONS These data provide support for the linkage between access and care seeking with primary care physicians.

The Validity of Measures of Socioeconomic Status of Adolescents.

This study examines the validity of measures of socioeconomic status (SES) as reported by adolescents. Adolescents completed a self-administered questionnaire that included eight measures of SES. Mothers also reported on selected measures of SES. Supporting criterion validity, adolescents and mothers had relatively high agreement on the SES measures. Older adolescents, those less involved in risk behaviors, and those who do better in school gave more accurate SES reports and/or were less likely to have missing SES data. Those in households without fathers were less likely to know fathers’ information. Income was not asked of the adolescents. However, most adolescent-reported SES questions varied systematically and in the expected direction with mothers’income report. In terms of construct validity, the SES measures related to adolescent health measures in the predicted way—that is, those with higher SES were more likely to report better physical and emotional health.

Primary Care Physician Specialty Referral Decision Making: Patient, Physician, and Health Care System Determinants

Purpose. To examine the effects of patient, physician, and health care system characteristics on primary care physicians’ (PCPs’) specialty referral decision making. Methods. Physicians (n = 142) and their practices (n = 83) located in 30 states completed background questionnaires and collected survey data for all patient visits (n = 34,069) made during 15 consecutive workdays. The authors modeled the occurrence of any specialty referral, which occurred during 5.2% of visits, as a function of patient, physician, and health care system structural characteristics. A subanalysis was done to examine determinants of referrals made for discretionary indications (17% of referrals), operationalized as problems commonly managed by PCPs, high level of diagnostic and therapeutic certainty, low urgency for specialist involvement, and cognitive assistance only requested from the specialist. Results. Patient characteristics had the largest effects in the any-referral model. Other variables associated with an increased risk of referral included PCPs with less tolerance of uncertainty, larger practice size, health plans with gatekeeping arrangements, and practices with high levels of managed care. The risk of a referral being made for discretionary reasons was increased by capitated primary care payment, internal medicine specialty of the PCP, high concentration of specialists in the community, and higher levels of managed care in the practice. Conclusions. PCPs’ referral decisions are influenced by a complex mix of patient, physician, and health care system structural characteristics. Factors associated with more discretionary referrals may lower PCPs’ thresholds for referring problems that could have been managed in their entirety within primary care settings.

Dropping the Baton: Specialty Referrals in the United States

CONTEXT In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines. METHODS This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. FINDINGS PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialists role during the referral episode (e.g., single consultation or continuing co-management). CONCLUSIONS There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

The case for a global rare-diseases registry

Rare diseases are a clinically heterogeneous group of about 6500 disorders, and in fewer than 200 000 individuals in the USA. They are commonly diagnosed during childhood, often inherited, and can have deleterious long-term eff ects. Although any one condition is rare, their cumulative public health burden is substantial, with 6–8% of people having a rare disease at some point during life. Because of the rarity, no single institution, and in many cases no single country, has suffi cient numbers of patients to do generalisable clinical and translational research. Geographic spread of patients has been a major impediment to recruitment into clinical trials. Most rare diseases do not have a specifi c International Classifi cation of Diseases code, which hampers research that uses existing databases. Before the USA, the its emphasis on public health research. Although a full analysis of all present funding for health research in India and what it is spent on is not available, the funding from both domestic and international sources has increased substantially in India over the past decade. What then are the key goals that policy should address to boost research towards health care for all in India? First, a national research tracking mech anism should be developed to guide funding and commissioning of highquality research into the major under-represented causes of disease burden and into neglected health-system issues. Second, a systematic plan is needed to make research initiatives more interactive with policies and implementation of health programmes, so that research is more relevant for the health system and policy, and the knowledge generated is used more often by policy makers. Third, rigorous evaluation research should become an essential component of all major population health programmes and policies, to understand how these could be refi ned to improve health outcomes and how the underserved segments of the Indian population could be better reached to improve health equity. For these goals to be achieved, the major national organisations attempting to strengthen health research in India should come together to provide eff ective stewardship. These organisations should collaboratively develop mechanisms that enable agreement on tangible medium-term and long-term targets for health research in the country, a plan of action, and methods to track progress in research utilisation to achieve health care for all in India. Although solutions for India will have to be tailored to its circumstances, there are useful lessons to be learnt from the systematic eff orts of other countries aimed at matching research with public health priorities to more eff ectively improve population health. *Lalit Dandona, V M Katoch, Rakhi Dandona Public Health Foundation of India, New Delhi 110070, India (LD, RD); Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA (LD); and Department of Health Research and Indian Council of Medical Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India (VMK) lalit.dandona@phfi .org