Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

https://www.jhsph.edu/sebin/k/a/2005_MQ_Starfield.pdf

Contribution of Primary Care to Health Systems and Health

Committee for assessing progress on implementing the recommendations of the institute of medicine report the future of nursing: leading change, advancing health

The low-birth-weight infant remains at much higher risk of mortality than the infant with normal weight at birth. In the neonatal period, when most infant deaths occur, the proportion of low-birth-weight infants, especially those with very low weight, is the major determinant of the magnitude of the mortality rates. Furthermore, differences in low-birth-weight rates account for the higher neonatal mortality rates observed in some groups, particularly those characterized by socioeconomic disadvantages. Much of the recent decline in neonatal mortality can be attributed to increased survival among low-birth-weight infants, apparently as a result of hospital-based services. The application of these services is currently considered cost-effective, although whether this will continue to be true in the future is unclear because of the increased survival of very tiny infants. Although low-birth-weight infants remain at increased risk of both postneonatal mortality and morbidity in infancy and early childhood, the risk is substantially smaller than that of neonatal death. In addition, these adverse later outcomes have not offset the gains achieved in the neonatal period. Nonetheless, the increased survival of high-risk infants raises concern about their future requirements for special medical and educational services and about the stress on their families. Despite increased access to antenatal services, only moderate declines in the proportion of low-birth-weight infants has been observed, and almost no change has occurred in the proportion of those with very low weight at birth. In addition, in many areas of the country the birth-weight-specific neonatal mortality rates are similar for groups at high and low risk of neonatal death. In view of these findings, continuation of the current decline in neonatal mortality and reduction of the mortality differentials between high- and low-risk groups require the identification and more effective implementation of strategies for the prevention of low-weight births.

The contribution of low birth weight to infant mortality and childhood morbidity.

We estimate how cost sharing, the portion of the bill the patient pays, affects the demand for medical services. The data come from a randomized experiment. A catastrophic insurance plan reduces expenditures 31 percent relative to zero out-of-pocket price. The price elasticity is approximately -0.2. We reject the hypothesis that less favorable coverage of outpatient services increases total expenditure (for example, by deterring preventive care or inducing hospitalization).

/pdf/health-insurance-and-the-demand-for-medical-care-evidence-13gpg9hn2l.pdf

Health insurance and the demand for medical care: evidence from a randomized experiment.

Objective:To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.Design:Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups g

/pdf/clinical-practice-guidelines-for-the-prevention-and-fvgclilv6m.pdf

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.

/pdf/a-2020-vision-of-patient-centered-primary-care-4stwrdyh32.pdf

A 2020 vision of patient-centered primary care.

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries...

/pdf/taking-the-pulse-of-health-care-systems-experiences-of-1kglzsusdr.pdf

Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System’s innovation strategy for care model redesign. Geisinger’s clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger’s characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform.

/pdf/continuous-innovation-in-health-care-implications-of-the-509d6ycvxg.pdf

Continuous Innovation In Health Care: Implications Of The Geisinger Experience

This paper reports on a 2004 survey of primary care experiences among adults in Australia, Canada, New Zealand, the United Kingdom, and the United States. The survey finds shortfalls in delivery of safe, effective, timely, or patient-centered care, with variations among countries. Delays in lab test results and test errors raise safety concerns. Failures to communicate, to engage patients, or to promote health are widespread. Aside from clinical preventive care, the United States performs poorly on most care dimensions in the study, with notable cost-related access concerns and short-term physician relation- ships. Contrasts across countries point to the potential to improve performance and to learn from international initiatives.

http://globalag.igc.org/elderrights/world/2004/fivecountries.pdf

Primary care and health system performance: adults' experiences in five countries.

Objective To document the child-rearing needs and pediatric health care experiences of parents with children from birth to 3 years old. Design A nationally representative sample of 2017 parents with children younger than 3 years using a 25-minute structured telephone questionnaire. Interviews were completed by 68% of the screened eligible respondents. The margin of sampling error for results at the 95% confidence level was ±3 percentage points. Results Seventy-six percent of children younger than 3 years were reported by parents to be in excellent health; 88% had a regular source of pediatric health care. Seventy-one percent of parents who received special pediatric services rated their child's physician as excellent in providing good health care. Seventy-nine percent of parents reported they could use more information in at least 1 of 6 areas of child rearing, and 53% wanted information in at least 3 areas. Forty-two percent had talked with their child's physician about "nonmedical" concerns; 39% of parents read to or looked at a picture book with their child on a daily basis; 51% of parents set daily routines for meals, naps, and bedtime. Breast-feeding and reading to the child on a daily basis were much more likely if a physician encouraged parents to do so. Conclusions Most parents view the pediatric health care system as meeting the physical health needs of their young children. Parents want more information and support on child-rearing concerns, yet pediatric clinicians often fail to discuss nonmedical questions with them. The interventions of pediatric clinicians can positively affect parental behavior. Pediatric practices should consider creative ways to reconstitute and augment their current services and systems of care.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/189340/poa7321.pdf

Karen Davis

Papers

A 2020 vision of patient-centered primary care.

Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries

Continuous Innovation In Health Care: Implications Of The Geisinger Experience

Primary care and health system performance: adults' experiences in five countries.

Listening to Parents: A National Survey of Parents With Young Children