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Contribution of primary care to health systems and health.

The Milbank Quarterly

United States, Delivery of Health Care, Evidence-Based Medicine, Global Health, Health Expenditures, Health Services Accessibility, Health Status, Humans, Physician-Patient Relations, Physicians, Family, supply & distribution, Primary Health Care, economics

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      Abstract

      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.

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      How many child deaths can we prevent this year?

      This is the second of five papers in the child survival series. The first focused on continuing high rates of child mortality (over 10 million each year) from preventable causes: diarrhoea, pneumonia, measles, malaria, HIV/AIDS, the underlying cause of undernutrition, and a small group of causes leading to neonatal deaths. We review child survival interventions feasible for delivery at high coverage in low-income settings, and classify these as level 1 (sufficient evidence of effect), level 2 (limited evidence), or level 3 (inadequate evidence). Our results show that at least one level-1 intervention is available for preventing or treating each main cause of death among children younger than 5 years, apart from birth asphyxia, for which a level-2 intervention is available. There is also limited evidence for several other interventions. However, global coverage for most interventions is below 50%. If level 1 or 2 interventions were universally available, 63% of child deaths could be prevented. These findings show that the interventions needed to achieve the millennium development goal of reducing child mortality by two-thirds by 2015 are available, but that they are not being delivered to the mothers and children who need them.
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        Treating individuals 2. Subgroup analysis in randomised controlled trials: importance, indications, and interpretation.

        Large pragmatic trials provide the most reliable data about the effects of treatments, but should be designed, analysed, and reported to enable the most effective use of treatments in routine practice. Subgroup analyses are important if there are potentially large differences between groups in the risk of a poor outcome with or without treatment, if there is potential heterogeneity of treatment effect in relation to pathophysiology, if there are practical questions about when to treat, or if there are doubts about benefit in specific groups, such as elderly people, which are leading to potentially inappropriate undertreatment. Analyses must be predefined, carefully justified, and limited to a few clinically important questions, and post-hoc observations should be treated with scepticism irrespective of their statistical significance. If important subgroup effects are anticipated, trials should either be powered to detect them reliably or pooled analyses of several trials should be undertaken. Formal rules for the planning, analysis, and reporting of subgroup analyses are proposed.
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          Explaining income-related inequalities in doctor utilisation in Europe.

          This paper presents new international comparative evidence on the factors driving inequalities in the use of GP and specialist services in 12 EU member states. The data are taken from the 1996 wave of the European Community Household Panel (ECHP). We examine two types of utilisation (the probability of a visit and the conditional number of positive visits) for two types of medical care: general practitioner and medical specialist visits using probit, truncated Negbin and generalised Negbin models. We find little or no evidence of income-related inequity in the probability of a GP visit in these countries. Conditional upon at least one visit, there is even evidence of a somewhat pro-poor distribution. By contrast, substantial pro-rich inequity emerges in virtually every country with respect to the probability of contacting a medical specialist. Despite their lower needs for such care, wealthier and higher educated individuals appear to be much more likely to see a specialist than the less well-off. This phenomenon is universal in Europe, but stronger in countries where either private insurance cover or private practice options are offered to purchase quicker and/or preferential access. Pro-rich inequity in subsequent visits adds to this access inequity but appears more related to regional disparities in utilisation than to other factors. Despite decades of universal and fairly comprehensive coverage in European countries, utilisation patterns suggest that rich and poor are not treated equally. Copyright 2004 John Wiley & Sons, Ltd.
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            Author and article information

            Journal
            16202000
            2690145
            10.1111/j.1468-0009.2005.00409.x

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