Equity in health Starfield, B
Canadian Medical Association journal (CMAJ),
2000-Feb-08, 20000208, Volume:
162, Issue:
3
Journal Article
Peer reviewed
Equity, the absence of systematic inequality across population groups, has become a politically legitimate and worldwide concern. It is now difficult to ignore the impact of disparities in income ...distribution, which have been increasing in most countries such that the rich are becoming relatively richer and the poor relatively poorer. The share of global income of the poorest 20% of the world's population dropped from 2.3% to 1.4% in the most recent 30 years, whereas the share of the richest 20% increased from 70% to 85%, thus doubling the ratio of the share of the richest to the share of the poorest from 30:1 to 61:1.(f.1) Concomitantly, there is mounting evidence that health is directly, and almost linearly, related to wealth across the social position gradient within most countries. Thus, poverty itself is not the only determinant of differences in health status within or across industrialized nations. Countries of equivalent overall wealth, as measured by gross national product per capita, achieve very different levels of health, however measured, according to the equity of their income distributions.(f.2) The same phenomenon occurs within countries, and even within highly industrialized countries. For example, in the United States, the populations of states and counties with more equitable distribution of income have better health as measured by a variety of indicators, including but not limited to total adjusted death rates, life expectancy at birth and infant mortality.(f.3)
Nearly 15 percent of children in the United States are inadequately insured because they lack health insurance for all or part of the year. In this issue of the
Journal,
Olson and colleagues
1
...describe the potent effect of inadequate insurance coverage on several aspects of access to services. They also examine several other effects of inadequate insurance coverage. Olson et al. characterized insurance coverage as full-year, part-year, or none and as private or public. The manifestations of compromised access to services were delays in seeking care, unmet medical care needs, unfilled prescriptions, no visits to doctors' offices, the lack of . . .
Conocer cómo asumen y desempeñan los médicos de asistencia infantil en Cataluña los atributos de la atención primaria (AP) (coordinación, globalidad y longitudinalidad).
Estudio cualitativo basado en ...grupos de discusión y entrevistas individuales semiestructuradas con pediatras cuyo perfil había sido definido previamente según características sociodemográficas y de formación. Se llevaron a cabo 2 grupos de discusión (5 y 4 personas respectivamente) y 5 entrevistas individuales. Los participantes respondieron dos preguntas: ¿cómo explicaríais vuestra función como pediatras de AP? y ¿cuál es vuestra opinión sobre la relación entre los pediatras de AP y los especialistas a los que deriváis a los pacientes? Se llevó a cabo un análisis de contenido temático.
Los pediatras asumen que la AP debe ser integral y tener en cuenta el contexto del niño/a. El vínculo que se establece con las familias es una característica definitoria de su función. Detectan deficiencias en su propia formación y escaso reconocimiento social e institucional de su trabajo. La coordinación con la atención especializada y la transferencia de información entre niveles no son satisfactorias. Se identifican como factores facilitadores el conocimiento personal, la formación común y las sesiones clínicas.
A pesar de su formación hospitalaria, los pediatras asumen los atributos de la AP. Se propone abordar los aspectos deficitarios, como la falta de formación en AP, y tener en cuenta el escaso reconocimiento institucional y social, así como las dificultades en la coordinación, para mantener un nivel de calidad elevado en la atención primaria a la población infantil.
Primary care (PC) paediatricians are trained mainly in the hospital setting, with little contact with PC. This study aimed to find out what perceptions and experiences they have on the attributes of PC (first contact, comprehensiveness and continuity of care) that are assumed and performed by PC paediatricians.
A qualitative study was performed based on focus groups and semi-structured individual interviews with paediatricians with pre-defined sociodemographic and speciality training characteristics. Two focus groups (5 and 4 people each) and 5 interviews were made. Participants responded to two questions: how would you explain your function as a primary care paediatrician? and what is your opinion on the relationship between primary care paediatricians and the specialists to whom your patients are referred? The conversations of the groups and interviews were recorded and transcribed, and a content analysis was performed.
Paediatricians assume that PC must be comprehensive, and take into account the context of the child. Paediatricians declare a lack in their training and poor social and institutional recognition. Coordination with specialists and the transfer of information are not satisfactory. Helpful factors are personal knowledge, the shared training and the face-to-face clinical sessions.
Despite their hospital-based training, paediatricians assume the attributes of PC. Difficulties in performing their function include poor adaptation of their training to PC, and little institutional and social recognition. Coordination with specialists is not satisfactory. Approaching these difficulties can help maintaining a high quality level in the care of the paediatric population.
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.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective. To examine the extent to which good primary‐care experience attenuates the adverse association of income inequality with self‐reported health.
Data Sources. Data for the study were drawn ...from the Robert Wood Johnson Foundation sponsored 1996–1997 Community Tracking Study (CTS) Household Survey and state indicators of income inequality and primary care.
Study Design. Cross‐sectional, mixed‐level analysis on individuals with a primary‐care physician as their usual source of care. The analyses were weighted to represent the civilian noninstitutionalized population of the continental United States.
Data Collection/Extraction Methods. Principal component factor analysis was used to explore the structure of the primary‐care indicators and examine their construct validity. Income inequality for the state in which the community is located was measured by the Gini coefficient, calculated using income distribution data from the 1996 current population survey. Stratified analyses compared proportion of individuals reporting bad health and feeling depressed with those with good and bad primary‐care experiences for each of the four income‐inequality strata. A set of logistic regressions were performed to examine the relation between primary‐care experience, income inequality, and self‐rated health.
Principal Findings. Good primary‐care experience, in particular enhanced accessibility and continuity, was associated with better self‐reported health both generally and mentally. Good primary‐care experience was able to reduce the adverse association of income inequality with general health although not with mental health, and was especially beneficial in areas with highest income inequality. Socioeconomic status attenuated, but did not eliminate, the effect of primary‐care experience on health. In conclusion, good primary‐care experience is associated not only with improved self‐rated overall and mental health but also with reductions in disparities between more‐ and less‐disadvantaged communities in ratings of overall health.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
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.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
The key features of a strong, functioning primary healthcare system are the ability to provide continuity of care and a comprehensive financing system. ...continuity of care has existed in the United ...Kingdom because every patient is registered with a general practitioner (a patient list system).
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
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. PUBLICATION ABSTRACT
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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