The relationship between the availability of primary care and specialty care and certain life chance indicators such as mortality rates and life expectancy is analyzed using the multiple regression procedure. Dependent variables are life chance indicators; independent variables were selected based on Starfield's and Blum's health determinant models and include socioeconomic environment, lifestyles, demographics, and medical care. The author also examines the rankings of states in terms of these indicators, using Spearman's rho coefficient. Among the medical care variables, primary care is by far the most significant variable related to better health status, correlating with lower overall mortality, lower death rates due to diseases of the heart and cancer, longer life expectancy, lower neonatal death rate, and lower low birth weight. In contrast, the number of specialty physicians is positively and significantly related to total mortality, deaths due to heart diseases and cancer, shorter life expectancy, higher neonatal mortality, and higher low birth weight. From a policy perspective, a likely implication is to reorient the medical profession from its current expensive, clinically based, treatment-focused practice to a more cost-effective, prevention-oriented primary care system.
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References
1.
PolitzerR. M.Primary care physician supply and the medically underserved. JAMA266: 104–109, 1991.
2.
HanftR.WhiteC.Support of Graduate Medical Education. Physician Payment Review Commission, Washington, D.C., 1990.
3.
Graduate Medical Education National Advisory Committee. Summary Report to the Secretary, Department of Health and Human Services (DHHS), Vol. 1. DHHS publication No. (HRA) 81–651. Health Resources Administration, Hyattsville, Md., 1980.
4.
Association of American Medical Colleges. AAMC Data Book. Washington, D.C., 1991.
5.
SchroederS. A.Physician supply and the U.S. medical marketplace. Health Aff., Spring 1992, pp. 235–243.
6.
National Center for Health Statistics. Health, United States, 1991. Public Health Service, Hyattsville, Md., 1992.
7.
SchroederS. A.SandyL. G.Specialty distribution of U.S. physicians: The invisible driver of health care costs. N. Engl. J. Med.328: 961–963, 1993.
8.
LeighJ. P.International comparison of physicians' salaries. Int. J. Health Serv. 22: 217–220, 1992.
9.
RubleeD. A.SchneiderM.International health spending: Comparisons with the OECD. Health Aff., Fall 1991, pp. 187–198.
10.
BantaH. D.KempK. B.The Management of Health Care Technologies in Ten Countries. Background Paper 4. Office of Technology Assessment, U.S. Congress, Washington, D.C., 1980.
11.
StarrP.The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. Basic Books, New York, 1982.
12.
U.S. Bureau of the Census. Current Population Reports, Series P25, No. 997. Washington, D.C., 1986.
13.
StarfieldB.Primary care and health. JAMA266: 2268–2271, 1991.
14.
SheaS.Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. J. Engl. J. Med.327: 776–781, 1992.
15.
DonabedianA.Twenty years of research on the quality of medical care, 1964–1984. Evaluation and the Health Professions3: 243–265, 1985.
16.
BergnerM.Measurement of health status. Med. Care23: 696–704, 1985.
17.
RiceD. P.Health status and national health priorities. West. J. Med.154: 294–302, 1991.
18.
Centers for Disease Control. Health status indicators: Definitions and national data. Statistical Notes1: 1–8, 1992.
19.
StarfieldB.Health services research: A working model. N. Engl. J. Med.289: 132–136, 1973.
20.
BlumH. L.Planning for Health, Ed. 2. Human Sciences Press, New York, 1981.
21.
LalondeM.A New Perspective on the Health of Canadians. Health and Welfare Canada, Ottawa, 1974.
22.
ShiL.The relation between primary care and life chances. J. Health Care Poor Underserved3: 321–335, 1992.
23.
Primary care called key to longer life. Washington Post, January 5, 1993.
24.
Study shows primary care services key to higher life expectancies. The Nation's Health, February 1993.
25.
More primary care doctors means healthier lives—study. Am. Med. News, January 18, 1993.
26.
Correlation found between numbers of primary care physicians and health status. Am. Acad. Fam. Physicians FP Update, February 10, 1993.
27.
Primary care saves lives, analysis shows. Chicago Sun Times, January 11, 1993.
28.
Primary care called best weapon. The State, January 19, 1993.
29.
MarstonW.Socioeconomic differentiation within Negro areas of American cities. Soc. Forces48: 165–175, 1968.
30.
MarshallH.SinnottJ.Urban structure and the black/white fertility differential: Examination of the ‘assimilationist’ model. Soc. Sci. Q.52: 588–601, 1972.
31.
JiobuR. M.Urban determinants of racial differentiation in infant mortality. Demography9: 603–615, 1972.
32.
LaveistT. A.Simulating the effects of poverty on the race disparity in postneonatal mortality. J. Public Health Policy2: 463–473, 1990.
33.
GouldJ.Quality of Life in American Neighborhoods: Levels of Affluence, Toxic Waste, and Cancer Mortality in Residential ZIP Code Areas. Westview Press, Boulder, Colo., 1986.
34.
KitagawaE.IlauserR. M.Differential Mortality in the United States, Harvard University Press, Cambridge, Mass., 1973.
35.
MillerM. K.StokesC. S.Health status, health resources, and consolidated structural parameters: Implications for public health care policy. J. Health Soc. Behav.19: 263–279, 1978.
36.
FarmerF. L.Poverty, primary care and age-specific mortality. J. Rural Health7: 153–169, 1991.
37.
HadleyJ.More Medical Care, Better Health?The Urban Institute Press, Washington, D.C., 1982.
38.
U.S. Department of Commerce and the Census Bureau. Statistical Abstracts of the United States. U.S. Government Printing Office, Washington, D.C., 1988–1992.
39.
StarfieldB.Primary care in the United States. Int. J. Health Serv. 16: 179–198, 1986.
40.
American Public Health Association. America's Public Health Report Card: A State-by-slate Report on the Health of the Public. Washington, D.C., November 1992.
41.
WrightS. R.Quantitative Methods and Statistics. Sage, Newbury Park, Calif., 1991.
42.
AngellM.Privilege and health: What is the connection?N. Engl. J. Med.329: 126–127, 1993.
43.
WilkinsonR. G.Income distribution and mortality: A ‘natural’ experiment. Sociol. Health Illness12: 391–412, 1990.
44.
PappasG.The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1968. N. Engl. J. Med.329: 103–109, 1993.
45.
KeilJ. E.Mortality rates and risk factors for coronary disease in black as compared with white men and women. N. Engl. J. Med.329: 73–78, 1993.
46.
GuralnikJ. M.Educational status and active life expectancy among older blacks and whites. N. Engl. J. Med.329: 110–116, 1993.
47.
National Center for Health Statistics. Health, United States, 1990. U.S. Public Health Service, Hyattsville, Md., 1991.
48.
MillerD. C.Handbook of Research Design and Social Measurement, Ed. 5. Sage, Newbury Park, Calif., 1991.
49.
SchefflerR.A Report of a Study on Manpower Policy for Primary Health Care. National Academy of Science, Washington, D.C., 1978.
50.
RaffelN. W.The U.S. Health System: Origins and Functions. Wiley, New York, 1980.
51.
RosenblattR.MoscoviceI.Rural Health Care. Wiley, New York, 1982.
52.
MilioN.Primary Care and the Public's Health. Lexington Books, Lexington, Mass., 1983.
53.
Institute of Medicine. A Manpower Policy for Primary Health Care. National Academy Press, Washington, D.C., 1978.
54.
MendenhallR. C.A national study of internal medicine and its specialties: II. Primary care in internal medicine. Ann. Intern. Med.91: 275–287, 1979.
55.
California Health Manpower Policy Commission. 16th Annual Report to the California Legislature. Office of Statewide Health Planning and Development, Sacramento, 1989.
56.
U.S. Health Resources and Services Administration. Supplement to Instructions for Preparing Competing Training Grant Application, (Form PHS-6025-1) for Grants for Residency Training in General Internal Medicine and General Pediatrics. Rockville, Md., 1991.
57.
CartlandJ.Medicaid state reports. Child health care. AAP research Update, p. 3. American Academy of Pediatrics, Elk Grove Village, Ill., 1991.
58.
MillisJ.The Graduate Education of Physicians: Report of the Citizens Commission on Graduate Medical Education. American Medical Association, Chicago, 1966.
59.
NobleJ.StarfieldB.FriedmanR.Assessment of the Development and Support of Primary Care Residency Training (General Internal Medicine and Pediatrics). Publication NTIS HRP-0907161. U.S. Department of Health and Human Services, Washington, D.C., 1987.
60.
ShelovS. P.Federally supported primary care training program and pediatric careers. Am. J. Dis. Child.141: 65–66, 1987.
61.
U.S. Department of Health and Human Services. Sixth Report to the President and Congress on the Status of Health Personnel in the United States. Publication HRS-P-OD-88-1. Washington, D.C., 1988.
62.
HannanE. L.Investigation of the relationship between volume and mortality for surgical procedures performed in New York state hospitals. JAMA262: 503–510, 1989.
63.
FarberB. F.KaiserD. L.WenzelR. P.Relation between surgical volume and incidence of postoperative wound infection. N. Engl. J. Med.305: 200–204, 1981.
64.
FloodA. B.ScottW. R.EwyW.Docs practice make perfect? I: The relation between hospital volume and outcomes for selected diagnostic categories. Med. Care22: 98–114, 1984.
65.
FloodA. B.ScottW. R.EwyW.Does practice make perfect? II: The relation between volume and outcomes and other hospital characteristics. Med. Care22: 115–125, 1984.
66.
ShowstackI. A.Association of volume with outcome of coronary artery bypass graft surgery. JAMA257: 785–789, 1987.
67.
HaslerB. S.Disability and aging. N. Engl. J. Hum. Serv.10: 22–27, 1990.
68.
U.S. Congress, Office of Technology Assessment. Health Care in Rural America. OTA-H-434. U.S. Government Printing Office, Washington, D.C., 1990.
69.
WoodrowK.HastingsD.TuE.Rural-urban patterns of marriage, divorce, and mortality: Tennessee, 1970. Rural Sociol. 43: 70–85, 1978.
70.
CliffordW.BrannonY. E.Rural-urban differentials in mortality. Rural Sociol. 50: 210–224, 1985.
71.
AusterR.LevesonI.SarachekD.The production of health: An exploratory study. J. Hum. Resources4: 411–436, 1969.
72.
SilverM.An econometric analysis of spatial variations in mortality rates. In Essays in the Economics of Health, edited by FuchsV., pp. 161–227. National Bureau of Economic Research, New York, 1972.
73.
U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives, conference edition. U.S. Government Printing Office, Washington, D.C., 1990.
74.
WarnerK. E.The Economics of Worksite Health-promotion Programs: A Review of the Literature, pp. 1–12. National Center for Health Promotion, Ann Arbor, Mich., 1988.
75.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. Home and Garden Bulletin No. 232. U.S. Government Printing Office, Washington, D.C., 1985.
76.
U.S. Bureau of the Census. U.S. Department of Commerce News. CB91-100. U.S. Department of Commerce, Washington, D.C., March 11, 1991.
77.
FreebornD. K.Consistently high users of medical care among the elderly. Med Care28: 527–540, 1990.
78.
JenningM. C.PorterM.The changing elderly market. Top. Health Care Financ. 17: 1–8, 1991.
79.
U.S. Department of Health and Human Services. Health Status of Minorities and Low-income Groups, Ed. 3. U.S. Government Printing Office, Washington, D.C., 1991.
80.
PolednakA. P.Racial and Ethnic Differences in Disease. Oxford University Press, New York, 1989.
