Managing Integration of Health Care System Article Analysis
Paper details:
Managing Integration of Health Care System Article Analysis
Locate an article on the subject matter for the readings of the week. Summarize the article. Be sure to include your opinion and of the information
contained in the article, as well as a reference page. Your This analysis should be 2-3 pages in length (including the reference page) and in APA
format.
THE ARTICLE IS ATTACHED AND THE INSTRUCTIONS FOR WRITING ALSO ATTACHED
Abstract
The abstract provides a brief, comprehensive summary of the paper. Abstracts should not exceed 120 words, unless otherwise stated, and should note
the major ideas of the paper. The abstract appears on a page by itself, (page 2), with title Abstract, as shown above, centered on the first line of
the page and is not bolded. Unlike all other paragraphs in the research paper, it is not indented. The Abstract should be one long paragraph with
no indentations.
Insert the Title of Your Paper Here Again (centered, exactly as on title page, not bolded)
Begin the first paragraph of the body of your paper here (indented). Introduce your reader to your topic and why you are writing about it.
The introduction does not need the heading Introduction to label it due to its location in the paper. When writing a research paper, you should
strive to write in the third person. Avoid using words like I, or this researcher will. Relative to formatting, APA dictates that there are now two
spaces after punctuation marks at the end of sentences. All text in your paper from beginning to end, including the References page, should be
double-spaced. Set your margins to one inch all around.
Beginning on your title page, double click in the header to place an abbreviated title of your paper in all capital letters. This is called the
Running head and should be flush left with the margin. Then using the page insert function, insert your page numbers starting page 1 on the title
page, located at the upper right margin. Your page numbers will automatically fall in proper order.
Insert a New Major Heading Here (bolded)
This is where you will continue the body of your paper, citing some background or history on the subject you have chosen for your paper.
Titles that are centered and bolded are called Level I Headings. You will most likely need to use subheadings like the one below, to indicate that
you are changing the focus of your discussion. It is not APA compliant to underline headings, or any other text for that matter, so do not underline
any text anywhere. Also, do not use any colors anywhere in your paper, just plain black and white. Some templates use colors and blocks around page
numbers. This is not APA compliant.
Level Two Heading (subheading)
As above, subheadings are left justified (not indented) and they need to be in upper and lower case letters and bolded. Do not underline
headings. Each main word is capitalized. Throughout your entire paper use 12-point font, either Times New Roman or Arial only (although others
might be easy to read or look pretty, nothing else is acceptable). Make sure your entire paper is left justified (align text left), not center
justified (center text). Center justified text stretches text out evenly across the page, but is not APA compliant.
In Text Citations
In-text citations are required in your paper and must be APA compliant relative to formatting. If you are not familiar with how to format
in-text citations, refer to your APA Publication Manual to appropriately cite references in your text. Do not use URL’s as in-text citations. URL’s
should only be used in your References page to indicate where you retrieved information.
Conclusion
Conclude your paper by briefly summarizing what you have already said throughout your paper. This is where it would be appropriate to cite
your opinions or to talk about what you learned about the topic you have researched and written about. The References page should be on a page by
itself. What that means, is regardless of where your Conclusion ends, always start your References page on a new page, and type the word References,
centered, not bolded, on the very first line. Do not use the words Resources, Reference (singular), Works Cited, etc. Use References.
References
American Psychological Association. (2009). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.
Cohen, L., Chávez, V., & Chehimi, S. (2007). Prevention is primary: Strategies for community well-being. San Francisco: Jossey-Bass.
Schneiderman, N., Speers, M. A., Silva, J. M., Tomes, H., & Gentry, J. H. (Eds.). (2001). Integrating behavioral and social sciences with public
health. Washington, DC: American Psychological Association.
NOTE: Your reference page is always last and begins on a new separate page like this. The title is just as you see it above. The following applies:
• All references are double spaced like the rest of your paper with the first line flush left with the margin and all lines after the first
line (of each individual reference) is indented as above. This is also referred to as a hanging indent.
• There are specific components for each of the various types of references used, (books, journals, magazines, websites, etc.) depending on the
type of reference you are listing. Check the APA Publication Manual to make sure you include all the appropriate components for your references.
• All references must be alphabetized A to Z, regardless of type of reference. See your APA Publication Manual for examples.
• If you cite a reference in the body of the text of your paper, the reference must be listed on this page and vice versa. If you have a
reference listed here, make sure you have cited it in your paper somewhere.
Commentary
Primary care and specialty care: a role reversal?
Knowledge about primary care has been
accumulating at a rapid rate. We know
what primary care is and what it does; in
contrast, we know almost nothing about
specialty care, except for that part of it
that takes place in the inpatient setting,
and even that knowledge is spotty and
unrepresentative.
Professor Pereira Gray has posed a
remarkable hypothesis: that there is role
reversal between specialists and primary
care physicians in that primary care
physicians can now claim responsibility
for a considerable proportion of lifesaving care, whereas specialists are
increasingly assuming the role of ‘remediators’. There is much to ponder in his
short exposition. His hypothesis is provocative. Can it be supported with
evidence?1
The UK leads the world in its
development of the primary care
role. In the USA, specialism rules
and the situation is not so clear
The answer depends on other considerations, particularly the organization
and financing of health systems and the
historical primary care orientation (or
lack of it) in health policy. Dr Pereira
Gray writes primarily from the viewpoint of the UK, a country that leads the
world in its development of the primary
care role. In the USA, specialism rules
and the situation is not so clear.
In the UK, specialists work in hospitals
(at least for those in the majority public
sector). In the USA, most specialty care is
provided by community-based physicians who usually have admitting privileges in the hospital but work primarily in
private offices. The assertions about
Correspondence: Barbara Starfield, University
Distinguished Professor, Johns Hopkins
School of Public Health, 624 North
Broadway, Room 452, Baltimore, Maryland
21205, USA. Tel.: +1 410 955 3737, Fax: +1
410 614 9046, E-mail: bstarfie@jhsph.edu
756
specialty care that Professor Pereira Gray
provides seem to deal with hospitalisations; the extent to which hospital outpatient specialty consultations are
included in his thinking is unclear.
In the USA, most specialty care
is provided by community-based
physicians who usually have
admitting privileges in the hospital but work primarily in private offices
Data on US hospitalizations2,3 do
not support a decrease in life-saving
work provided by specialists. In the
30 years from 1970 to 2000, rates
(non-age-adjusted) of discharge have
increased for pneumonia, chronic bronchitis, asthma, cellulitis, cerebrovascular disease, acute myocardial infarction
and congestive heart failure. It is most
likely that these hospitalizations are
life-saving. Rates have fallen for diabetes mellitus, perhaps the major condition for which primary care, or a
combination of primary and specialty
care, can take credit for prolonging life.
In the palliative category, rates of
hospitalization have risen for osteoarthritis, but fallen for intervertebral disc
problems and fractures – probably a
result of better consultative and
interventionist care by specialists in
outpatient settings. Thus, the US data
provide, at best, mixed support for the
hypothesis, but remember that these
are data from a specialist-oriented
health system.2,3
Primary care both reduces
unnecessary visits to specialists
and increases the likelihood of
appropriate ones and, hence, is
part of the benefits attributed to
specialty care
That primary care physicians assume
responsibility for most of the care for
people with conditions that are not rare
(at least for the nonelderly) cannot be
denied, even in the USA. Even for those
with extensive co-morbidity, people
make more visits to primary care physicians than to specialists, both for the
condition itself and for co-morbid conditions.4 Consistent with the personfocused nature of primary care practice,
the number of visits for co-morbid
conditions exceeds the number of visits
for the condition itself (even for the
common chronic conditions that occupy
so much attention in health policy
deliberations). The same, however, is
not the case for the elderly, for which
preliminary analyses indicate a relatively
high frequency of visits to specialists
except for people with little co-morbidity. This may be a result simply of the
greater degree of co-morbidity in the
elderly, even within morbidity categories (B Starfield et al., in preparation).
John Bunker and colleagues5 have
estimated that about half the increase in
life expectancy over the most recent
half-century is a result of health services;
they estimate that about a third of this is
a result of primary care interventions.
Considering that the role of primary
care in the 20th century must have
included palliation of symptoms, which
would not be reflected in mortality
statistics, this estimate of the benefits
of primary care is surely too small,
especially because primary care both
reduces unnecessary visits to specialists
and increases the likelihood of appropriate ones and, hence, is part of the
benefits attributed to specialty care.
What is becoming increasingly clear
is that new relationships between primary care physicians and specialists are
in order. Studies in the USA, which
have included family physicians and
paediatricians (who often serve as primary care physicians to children), show
that co-ordination between primary care
physicians and specialists is poor. Less
Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:756–757
Primary and specialty care
•
757
B Starfield
than half of family physicians knew
whether a referral to the specialist actually resulted in a visit; of those where it
did, four of five referrals resulted in a
feedback letter, but this was the case for
only 55% of pediatricians6. Outcomes
of the referrals were clearly better when
there was communication; satisfaction
with the referral, perceived benefit to
management and perceived educational
benefit were best when there was both a
letter and a telephone communication,
less than whether there was either one
and least when there was neither.
Expectations for the referral indicated
the imperative for more shared care
between primary care physicians and
specialists. About half of all referrals
were for time-limited consultation for
either advice or, more commonly, for
definitive tests or procedures, with no
long-term transfer of responsibility. Between one in seven and one in four
referrals (in family practice and paediatrics, respectively) had an expectation
for transferred management, presumably for the care of conditions that occur
too uncommonly in primary care practice for the practitioner to maintain
competence even with consultation.
For about one-third, however, there
was a clear preference for shared management over time. Although these percentages vary among different types of
specialists, the findings pertain to the
vast majority of types of specialists to
which there was a referral.7
The difference between the two
countries in expectations of specialists is suggested by differences
in referral frequencies responsibility for health services may be
increasingly shared between primary care and specialty care; the
roles might be blended rather
than reversed
This preference for shared management is evidence of the interest in
person-focused care on the part of primary care physicians. However, in the
USA, and possibly in the UK, there is an
absence of clarity in use of the term
‘continuity of care’. A recent US study
demonstrated a considerable increase
between 1997 and 2001 in the perception of specialists that they provide
‘continuing relationships’ for their patients.8 Whether this continuity of care is
person-focused (often termed ‘longitudinality’ – a primary care characteristic) or
disease-focused was not considered.
Failure to make this distinction blurs
the distinction between primary care and
specialty care, and is a critical deterrent
to rational planning and organization of
health services delivery. The difference
between the two countries in expectations of specialists is suggested by differences in referral frequencies in the
two countries; in the USA, case-mixadjusted frequencies of referrals (percentage of people referred in a year) is
two and a half times that in the UK –
about 35% versus 14%.9 Studies of the
nature of, and expectation for, referrals
in the UK would be very enlightening,
particularly in view of the relative clarity
in the distinction between primary care
and specialty care in this country.
Thus, it seems likely that responsibility for health services may be increasingly shared between primary care and
specialty care; the roles might be blended rather than reversed. As noted
above, we now are quite clear on the
role of primary care; there seems to be
widespread acceptance of its unique
characteristics (first contact care in the
case of new or newly recurring illnesses,
longitudinality, comprehensiveness of
services for all conditions except those
too rare to maintain competence and coordination). The same cannot be said
about specialty care. If we are truly to
understand the relative roles of primary
care physicians and specialists, and how
they might increasingly share responsibility for people and populations, we
shall first have to clearly understand
what specialty care is.
Acknowledgements
This work was supported in part by
Grant no. 6 U30 CS 00189–05 S1 R1
Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:756–757
of the Bureau of Primary Health Care,
Health Resources and Services Administration, Department of Health and
Human Services, to the Primary Care
Policy Centre for the Underserved at
Johns Hopkins University.
References
1 Pereira Gray D. Role reversal between
primary and secondary care. Med Educ
2003;37:754–755.
2 Ranofsky AL. Inpatient Utilization of
Short-stay Hospitals, By Diagnosis, United
States. Data from the National Health
Survey 13(16). DHEW publication,
(HRA) 75–1767. National Center for
Health Statistics, Washington, DC,
1975.
3 Kozak LJ, Hall MJ. National Hospital
Discharge Survey. Annual Summary with
Detailed Diagnosis and Procedure Data.
Vital Health Statistics 13(153). National
Center for Health Statistics, Washington, DC, 2002.
4 Starfield B, Lemke KW, Bernhardt T,
Foldes SS, Forrest CB, Weiner JP.
Co-morbidity. implications for the
importance of primary care in case
management. Ann Fam Pract 2003;
(in press).
5 Bunker J, Horder J, Starfield B. Can the
benefits of primary care be measured?
Lessons from America 2003 (in press).
6 Forrest CB, Glade GB, Baker AE,
Bocian A, von Schrader S, Starfield B.
Co-ordination of specialty referrals and
physician satisfaction with referral care.
Arch Pediatr Adolesc Med 2000;154:499–
506.
7 Starfield B, Forrest CB, Nutting PA,
von Schrader S. Variability in physician
referral decisions. J Am Board Fam Pract
2002;15:473–80.
8 Hargraves JL, Pham HH. Back in the
Driver’s Seat: Specialists Regaining
Autonomy. Tracking Report no. 7, January. Center for Studying Health System
Change, Washington, DC, 2003.
9 Forrest CB, Majeed A, Weiner JP,
Carroll K, Bindman AB. Comparison of
specialty referral rates in the United
Kingdom and the United States:
retrospective cohort analysis. BMJ
2002;325:370–1.
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