Two main avenues are advocated to improve the capability of healthcare systems to satisfy the public's needs and expectations: more resources and better organization. This paper sheds some light on this debate. It assesses the extent to which patients' positive rating of their healthcare experience and the extent to which they use services are related to the availability of healthcare resources. Findings indicate that patients' evaluations of their care experience and use of services were higher when the availability of resources was either limited or average. In no case were positive ratings of services and greater use of them associated with greater resource availability. Thus, simply adding resources runs the risk of diminishing, rather than improving, users' healthcare experience.

Catechol-O-methyltransferase (COMT) is a major enzyme controlling catecholamine levels that plays a central role in cognition, affective mood and pain perception. There are three common COMT haplotypes in the human population reported to have functional effects, divergent in two synonymous and one nonsynonymous position. We demonstrate that one of the haplotypes, carrying the non-synonymous variation known to code for a less stable protein, exhibits increased protein expression in vitro. This increased protein expression, which would compensate for lower protein stability, is solely produced by a synonymous variation (C166T) situated within the haplotype and located in the 5′ region of the RNA transcript. Based on mRNA secondary structure predictions, we suggest that structural destabilization near the start codon caused by the T allele could be related to the observed increase in COMT expression. Our folding simulations of the tertiary mRNA structures demonstrate that destabilization by the T allele lowers the folding transition barrier, thus decreasing the probability of occupying its native state. These data suggest a novel structural mechanism whereby functional synonymous variations near the translation initiation codon affect the translation efficiency via entropy-driven changes in mRNA dynamics and present another example of stable compensatory genetic variations in the human population.

OBJECTIVE

To investigate variations in accessibility, continuity of care, and coordination of services as experienced by patients in Quebec on the eve of major reforms, and to provide baseline information against which reforms could be measured.

DESIGN

Multilevel cross-sectional survey of practice.

SETTING

One hundred primary health care settings were randomly selected in urban, suburban, rural, and remote locations in 5 health regions in Quebec.

PARTICIPANTS

In each clinic, we chose up to 4 physicians and 20 consecutive patients consulting each physician.

MAIN OUTCOME MEASURES

Patients’ responses to a self-administered questionnaire, the Primary Care Assessment Tool, that assessed patient-provider affiliation, accessibility, relational continuity, coordination of primary and specialty care, and whether patients received health promotion and preventive services.

RESULTS

A total of 3441 patients participated (87% acceptance rate) in 100 clinics (64% response rate). Timely access was difficult; only 10% expressed confidence they could be seen by their regular doctors within a day if they became suddenly ill. Average waiting time for a doctor’s appointment was 24 days. Coordination of care with specialists was at minimally acceptable levels. Patients with family physicians recalled them addressing only 56% of the health promotion and preventive issues appropriate for their age and sex, and patients without family physicians recalled physicians addressing substantially fewer (38%). Most patients reported they were highly confident that their physicians knew them well and would manage their care beyond clinical encounters (relational continuity). The exception was the 16% of patients overall who did not have family physicians (34% of patients at walk-in clinics).

CONCLUSION

This survey highlights serious problems with accessibility. Improvement is needed urgently to avoid deterioration of patients’ confidence in the healthsystem even though patients rate their relationships with their physician highly. Health promotion, preventive services, and coordination with specialists also needed to be improved, and careful thought must be given to the plight of those without family physicians.