Attachment--and loss.

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

Background There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation. Methods From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration Results There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients. Conclusions The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

https://www.nejm.org/doi/pdf/10.1056/NEJM199701233360402

A prediction rule to identify low-risk patients with community-acquired pneumonia

With advances in the effectiveness of treatment and disease management, the contribution of chronic comorbid diseases (comorbidities) found within the Charlson comorbidity index to mortality is likely to have changed since development of the index in 1984. The authors reevaluated the Charlson index and reassigned weights to each condition by identifying and following patients to observe mortality within 1 year after hospital discharge. They applied the updated index and weights to hospital discharge data from 6 countries and tested for their ability to predict in-hospital mortality. Compared with the original Charlson weights, weights generated from the Calgary, Alberta, Canada, data (2004) were 0 for 5 comorbidities, decreased for 3 comorbidities, increased for 4 comorbidities, and did not change for 5 comorbidities. The C statistics for discriminating in-hospital mortality between the new score generated from the 12 comorbidities and the Charlson score were 0.825 (new) and 0.808 (old), respectively, in Australian data (2008), 0.828 and 0.825 in Canadian data (2008), 0.878 and 0.882 in French data (2004), 0.727 and 0.723 in Japanese data (2008), 0.831 and 0.836 in New Zealand data (2008), and 0.869 and 0.876 in Swiss data (2008). The updated index of 12 comorbidities showed good-to-excellent discrimination in predicting in-hospital mortality in data from 6 countries and may be more appropriate for use with more recent administrative data.

/pdf/updating-and-validating-the-charlson-comorbidity-index-and-u1djuhty32.pdf

Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries

Principles and Practice of Structural Equation Modeling (2nd ed.)

As part of an ongoing effort to evaluate alternative treatments for benign prostatic hyperplasia, we compared the outcomes of transurethral resection of the prostate with those of open prostatectomy. Men undergoing prostatectomy in Denmark (n = 36,703), Oxfordshire, England (n = 5284), and Manitoba, Canada (n = 12,090), were identified retrospectively through administrative data and followed for up to eight years. The cumulative percentage of patients undergoing a second prostatectomy was substantially higher after transurethral than after open prostatectomy (12.0 vs. 4.5 percent in Denmark, 12.0 vs. 1.8 percent in Oxfordshire, and 15.5 vs. 4.2 percent in Manitoba). The long-term age-specific mortality rates associated with transurethral prostatectomy as compared with open prostatectomy were also elevated in each country. The data on 1650 Canadian patients were used to investigate the contribution of coexisting morbid conditions to the elevated risk of death. The relative risk was 1.45 (95 percent confidence interval, 1.15 to 1.83) before risk adjustment and 1.45 (95 percent confidence interval, 1.15 to 1.84) after adjustment; the higher mortality was seen among low-risk as well as high-risk patients. These findings suggest that transurethral prostatectomy is less effective in overcoming urinary obstruction than the open operation. Our data also raise the possibility that transurethral prostatectomy may result in higher long-term mortality, although we cannot rule out potential confounding effects of unmeasured characteristics of patients.

Mortality and Reoperation after Open and Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia

Data maintained by medical insurance plans can be used to evaluate the incidence of death and nonfatal complications following medical care, to test hypotheses about the outcomes of care, and to identify hospitals with unusually high or low death rates. These uses are illustrated for prostatectomy, utilizing claims data from the Maine Medicare and Manitoba Health Services Commission files. The study shows important differences in death rates between individual hospitals and higher cumulative probability of reoperation following transurethral compared with open prostatectomy. The advantages of claims data are low cost, ease of patient follow-up over long periods, and the absence of reporting bias. The limitations are the adequacy of the data used to control for patient comorbidity and the lack of outcome information on functional status. The effective use of claims data for monitoring requires the active participation of physicians in improving the data base and interpreting the findings. ( JAMA 1987;257:933-936)

Use of claims data systems to evaluate health care outcomes. Mortality and reoperation following prostatectomy.

In Manitoba, Canada, a representative cohort of elderly individuals ages 65 to 84 (n = 3,573) were interviewed in 1971 and the survivors of this cohort were reinterviewed in 1983 This analysis assesses the determinants of successful aging--whether or not an individual will live to an advanced age, continue to function well at home, and remain mentally alert Over 100 separate indicators of demographic and socio-economic status, social supports, health and mental status in 1971 were available as potential predictors of successful aging Indicators of access to health care over the period 1970-82 and indicators of diseases over this period were also available as predictors Those who aged successfully were shown to have greater satisfaction with life in 1983 and to have made fewer demands on the health care system than those who aged less well Despite the large number of potential predictors of successful aging which were examined, only age, four measures of health status, two measures of mental status, and not having one's spouse die or enter a nursing home were shown to be predictive of successful aging

Predictors of successful aging: a twelve-year study of Manitoba elderly.

Health varies with socioeconomic status; those with higher incomes or who are better educated can expect to have better health. The success of the Canadian universal health care system in delivering care according to need was assessed. Consistent gradients in all-cause and cause-specific mortality according to neighborhood income characteristics are evident among Winnipeg residents. Poorer, less healthy groups receive more acute hospital care and have more contacts with general practitioners. Surgical rates and contacts with specialist physicians however, show less variation by socioeconomic status. One reason may be that members of higher socioeconomic groups have the skills required to negotiate for surgery when they develop conditions, like joint pain, that are less critical. The move toward organized priority lists in Canada may remedy this situation. As access to health care is more equalized, improvement in the health of lower and middle socioeconomic groups will occur through changes in social policy like improvement of educational opportunities.

/pdf/variation-in-health-and-health-care-use-by-socioeconomic-4o1757wupx.pdf

Variation in Health and Health Care Use by Socioeconomic Status in Winnipeg, Canada: Does the System Work Well? Yes and No

BACKGROUND While the adjusted clinical group (ACG) system has been extensively validated in the United States, its use in other developed nations has been limited. This article examines the performance of the system in 2 Canadian provinces and assesses the extent to which ACGs can account for same-year and next-year health care expenditures. METHODS The study population included all residents of Manitoba and British Columbia who were continuously enrolled in the provincial health plans from April 1, 1995, to March 31, 1997. ACGs were assigned through diagnoses from fee-for-service physician claims and hospital separation records. "Physician" costs were calculated from the fee-for-service tariffs, and for Manitobans, "total" costs were also computed by combining physician and hospital costs. Linear regression was used to examine the ability of the ACG system to explain variation in individual costs (truncated at the 99th percentile). RESULTS The British Columbia and Manitoba data were generally acceptable, with fewer than 2% rejected diagnoses. Higher costs were associated with both the accumulation of morbidities and their relative severity. For physician costs, the ACG system explained approximately 50% and approximately 25% of the variation in same-year and next-year truncated costs, respectively. For total costs, the system explained approximately 40% and approximately 14% of these respective costs. CONCLUSIONS The application of ACGs in Canada is feasible using existing data. The ability of the ACG system to explain variation in costs is similar to that found in US health systems. While application of ACGs in Canada shows promise, further research is required to examine how closely they reflect population morbidity burdens and health care needs.

Noralou P. Roos

Papers

Mortality and Reoperation after Open and Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia

Use of claims data systems to evaluate health care outcomes. Mortality and reoperation following prostatectomy.

Predictors of successful aging: a twelve-year study of Manitoba elderly.

Variation in Health and Health Care Use by Socioeconomic Status in Winnipeg, Canada: Does the System Work Well? Yes and No

Performance of the ACG case-mix system in two Canadian provinces.