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1.  Effects of Primary Care Coordination on Public Hospital Patients 
OBJECTIVE
To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients.
DESIGN
Prospective randomized gatekeeper intervention, with 1-year follow-up.
SETTING
The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital.
PATIENTS
We studied 2,293 established patients of 28 primary care physicians.
INTERVENTION
Patients were randomized based on their primary care physician's main clinic day. The 1,121 patients in the intervention group (Ambulatory Patient–Physician Relationship Organized to Achieve Coordinated Healthcare [APPROACH] group) required primary care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did not.
MEASUREMENTS AND MAIN RESULTS
Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability of the gatekeeping model was determined via patient satisfaction surveys.
RESULTS
Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P =.04; 95% confidence interval [CI]−1.05 to −0.01). While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients, this difference was not statistically significant (P =.14; 95% CI, −0.11 to 0.66). Changes in low-acuity ED care were similar between the two groups (0.06 visits per year more in APPROACH group than control group, P =.42; 95% CI, −0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients (P =.02; 95% CI, −0.26 to −0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network services between the 2 groups were similar.
CONCLUSIONS
A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients.
doi:10.1046/j.1525-1497.2000.07010.x
PMCID: PMC1495451  PMID: 10840268
primary care; coordination; public hospital patients; gate keeping; utilization
2.  Measuring the need for medical care in an ethnically diverse population. 
Health Services Research  1996;31(5):551-571.
OBJECTIVE: To examine measures of need for health care and their relationship to utilization of health services in different racial and ethnic groups in California. DATA SOURCE: Telephone interviews obtained by random-digit dialing and conducted between April 1993 and July 1993 in California, with 7,264 adults (ages 18-64): 601 African Americans, 246 Asians, 917 Latinos interviewed in English; 1,045 Latinos interviewed in Spanish; and 4,437 non-Latino whites. STUDY DESIGN: A cross-sectional survey was conducted from a stratified, probability telephone sample. DATA COLLECTION: Interviews collected self-reported indicators of need for health care: self-rated health, activity limitation, major chronic conditions, need for ongoing treatment, bed days, and prescription medication. The outcome was self-reported number of physician visits in the previous three months. PRINCIPAL FINDINGS: Compared to whites, one or more of the other ethnic groups varied significantly (p < .05) on each of the six need-for-care measures after adjustment for health insurance, age, sex, and income. Latinos interviewed in Spanish reported lower percentages and means on five of the need measures but the highest percentage with fair or poor health (32 percent versus 7 percent in whites). Models regressing each need measure on the number of outpatient visits found significant interactions of ethnic group with need compared to whites. After adjustment for insurance and demographics, the estimated mean number of visits in those with the indicator of need was consistently lower in Latinos interviewed in Spanish, but the differences among the other ethnic groups varied depending on the measure used. CONCLUSION: No single valid estimate of the relationship between need for health care and outpatient visits was found for any of the six indicators across ethnic groups. Applying need adjustment to the use of health care services without regard for ethnic variability may lead to biased conclusions about utilization.
PMCID: PMC1070141  PMID: 8943990
4.  California physicians' willingness to care for the poor. 
Western Journal of Medicine  1995;162(2):127-132.
Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.
PMCID: PMC1022646  PMID: 7725684
5.  Primary and managed care. Ingredients for health care reform. 
Western Journal of Medicine  1994;161(1):78-82.
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.
PMCID: PMC1011384  PMID: 7941522
6.  A brief history of health care quality assessment and improvement in the United States. 
Western Journal of Medicine  1994;160(3):263-268.
We review the history and current efforts to assess and improve health care in the United States. This process has involved a host of government agencies and commissions, professional organizations, insurance underwriters, corporations, and more recently, market forces. Traditional approaches to quality control have stressed case-by-case analysis and identifying outliers. Newer approaches include creating practice guidelines and profiles of hospitals and physicians. The joint goals of quality improvement and cost control can best be realized if institutions and practitioners embrace these new approaches and use them to enhance their performances.
PMCID: PMC1022402  PMID: 8191769

Results 1-6 (6)