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Pharmacists are more often being recognized as a critical component of the primary care team. Previous literature has not clearly made the connection to how pharmacists and comprehensive medication management (CMM) contribute to recognized foundational elements of primary care. In this reflection, we examine how the delivery of CMM both supports and aligns with Starfield's 4 Cs of Primary Care. We illustrate how the delivery of CMM supports first contact through increased provider access, continuity through empanelment, comprehensiveness by addressing unmet medication needs, and coordination through collaborating with the primary care team and broader team. The provision of CMM addresses critical unmet medication-related needs in primary care and is aligned with the foundational elements of primary care.

Resumo Os pilares Starfield são revistos assim como o sistema de saúde canadense. Avaliação objetiva e subjetiva são aplicadas ao sistema sob as lentes do acesso, longitudinalidade, integralidade e coordenação de cuidados. Discutem-se as vulnerabilidades do sistema e as ações e propostas que estão em curso para tentar melhorar esses aspectos, tanto nacionalmente como na província de Ontário. Destaque para a oportunidade de se criar um sistema gratuito de medicamentos e os diversos desafios para avançar a agenda de reformas. Abstract This paper reviews the Starfield pillars and the Canadian health system. An objective and subjective evaluation are applied to the system through the lenses of access, longitudinality, integrality, and coordination of care. System vulnerabilities, actions, and proposals that are underway to improve these aspects, both nationally and in the province of Ontario, are discussed. Worth highlighting is the opportunity to establish a national free drug system, and the several challenges to advance the agenda of reforms.

We are now at the end of the beginning of re-envisioning the future of residency education in Family Medicine. On December 6-7, 2020, after almost a year of preparation, representatives of the specialty came together at the fourth Starfield Summit to review the past and present, and to envision the

The training family medicine residents receive will have a lasting impact on how they deliver care in the future. Evidence demonstrates an imprinting effect based on the training environment itself. Thus, residency training represents a critical time for establishing clinical experiences that embody core primary care principles and ensure excellent care delivery. This paper focuses on the clinical experience in the family medicine practice setting. We have used Starfield’s four C’s of primary care and added two more: cost and community, as the tools to achieve the triple aim. In reviewing the current state of residency programs across the country, we noted that there was a lack of measurement on how programs were performing when it came to the six C’s. We will briefly describe some recent innovative collaboratives among residencies. Next, we examine the six C’s of primary care in context of current care. These six C’s inform our recommendations for residency training standards to create the family physicians of the future. The overarching theme of these recommendations is the need to measure and report on what we want to ultimately improve.

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care’s salutary effects. We first revisit these “4C’s”—first Contact, Continuity, Comprehensiveness, and Coordination—and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these “7C’s,” functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored (“4T’s”) care of patients and populations.

The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN’s face in chronic disease management. The objective of this study is to map features of PCN to Starfield’s “4Cs” framework. The “4Cs” of primary care—comprehensiveness, first contact access, coordination and continuity—offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN’s empowering features that fulfil the “4Cs”. On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the “4Cs”. However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management. Ministry of Health (MOH) National Medical Research Council (NMRC) Published version This study was funded by two grants. The National Medical Research Council (NMRC) and Ministry of Health (MOH), Singapore, Health Service Research Grant (HSRG) (Funding Number: NMRC/HSRG/0086/2018) and the Centre Grant Programme Singapore Population Health Improvement Center (Funding Number: NMRC/CG/C026/2017_NUHS).

Several middle and upper income countries carry out household surveys that seek to trace the profile of access and use of health services. Probably one of the most ambitious examples is Brazil, with its National Health Survey (PNS-2019). We evaluated PNS-2019, presenting in an unprecedented way, one of its innovations, which refer to Starfield and Shi's adult Primary Care Assessment Tool (PCAT).Based on a cross-sectional study, we evaluated Module H of the PNS-2019, which interviewed a probabilistic sample of about 10,000 adults in 2019 in all 27 Brazilian states. According to the PCAT methodology, an average score equal to or above 6.6 indicates a greater orientation and quality of the evaluated primary care services.Brazilian overall PCAT score [5, 9] reveals the need to improve primary health care services across the country. There were no statistically significant differences in the scores by sex (men and women, 5.9), and race (whites 5.9 [5.7; 6.0] and brown / black 5.9 [5.8; 6.0]). On the other hand, there was a difference in terms of age. The elderly evaluated the services in a more positive way (score = 6.1 [6.0; 6.2]), when compared to those aged 40-59 years (5.9 [5.7; 6.0]) and 18 to 39 years (5.6 [5.5; 5.8]). First results of PNS-2019 show that the population that most needs primary care services in SUS is the one with the best perception and the most positive evaluation of the actions and procedures offered in health facilities.During 2019, Brazil undertook important structural reforms in PHC based on a new financing model with the aim of inducing an improvement in efficiency and strengthening its attributes. It is essential that countries with universal health coverage (UHC) guarantee access to their population and, especially, the most vulnerable, seek better efficiency of these services and regularly assess PHC based on the population's perception, through an independent methodology that monitor the quality of services and the strength of PHC, generating value for public resources applied to health services.INTRODUçãO: Vários países de renda média e alta realizam pesquisas domiciliares que procuram traçar o perfil de acesso e uso dos serviços de saúde. Provavelmente um dos exemplos mais ambiciosos é o Brasil, com sua PNS. Avaliamos esse inquérito e apresentamos, de forma inédita uma de suas inovações, que se refere ao uso do instrumento Primary Care Assessment Tool (PCAT). MéTODOS: Com base em um estudo transversal, avaliamos o Módulo H da PNS-2019, que entrevistou uma amostra probabilística de cerca de 10.000 adultos em 2019 em todos os 27 estados brasileiros. De acordo com a metodologia do PCAT, um escore médio igual ou acima de 6,6 indica uma maior orientação e qualidade dos serviços de atenção primária avaliados.O escore médio geral do PCAT no Brasil foi de 5,9, revelando a necessidade de melhoria dos serviços de atenção primária à saúde em todo o país. Não houve diferenças estatisticamente significantes nos escores por sexo (homens e mulheres, 5,9) e raça (brancos 5,9 [5,7; 6,0] e pardos / pretos 5,9 [5,8; 6,0]). Por outro lado, houve diferença em termos de idade. Os idosos avaliaram os serviços de forma mais positiva (escore = 6,1 [6,0; 6,2]), quando comparados aos de 40–59 anos (5,9 [5,7; 6,0]) e 18 a 39 anos (5,6 [5,5; 5,8]). Os primeiros resultados da PNS-2019 mostram que a população que mais necessita dos serviços de atenção básica no SUS é aquela que tem melhor percepção e avaliação mais positiva das ações e procedimentos oferecidos nas unidades de saúde. DISCUSSãO: Durante o ano de 2019, o Brasil fez reformas estruturais importantes na APS a partir de um novo modelo de financiamento, com o objetivo de induzir uma melhoria da eficiência e fortalecer seus atributos. É fundamental que países com sistemas de saúde de cobertura universal, garantam acesso a sua população e, em especial, aos mais vulneráveis; busquem melhor eficiência desses serviços e avaliem regularmente a APS a partir da percepção da população, por meio de uma metodologia independente que monitore a qualidade dos serviços e a força da APS, gerando valor aos recursos públicos aplicados nos serviços de saúde.

In this BJGP Open collection, we examine how international primary care systems have performed in response to COVID-19. The past few months have seen rapid change and adaption of primary care systems to meet unprecedented new challenges. The pandemic has also exposed critical weaknesses in systems all over the world.1 The World Health Organization (WHO) and the World Organization of Family Doctors (WONCA) contend that an ideal primary care system should fulfil the core characteristics laid out by Barbara Starfield:2 primary care should be accessible, affordable, available at the time of need, and represent the ‘front-door’ to the health system. It should provide ongoing care and coordination with other specialists and focus on individuals and their families beyond their biological disease.3,4 The Astana Declaration5 and the WHO Vision for Primary Health Care in the 21st Century 6 also make a case for empanelment (working for a listed or geographically defined population) and a model of primary care that is engaged with …

Human cognitive processes in wayfinding may differ depending on the time taken to accept visual information in environments. This study investigated users&rsquo, wayfinding processes using eye-tracking experiments, simulating a complex cultural space to analyze human visual movements in the perception and the cognitive processes through visual perception responses. The experiment set-up consisted of several paths in COEX Mall, Seoul&mdash, from the entrance of the shopping mall Starfield to the Star Hall Library to the COEX Exhibition Hall&mdash, using visual stimuli created by virtual reality (four stimuli and a total of 60 seconds stimulation time). The participants in the environment were 24 undergraduate or graduate students, with an average age of 24.8 years. Participants&rsquo, visual perception processes were analyzed in terms of the clarity and the recognition of spatial information and the activation of gaze fixation on spatial information. That is, the analysis of the visual perception process was performed by extracting &ldquo, conscious gaze perspective&rdquo, data comprising more than 50 consecutive 200 ms continuous gaze fixations, &ldquo, visual understanding perspective&rdquo, data were also extracted for more than 300 ms of continuous gaze fixation. The results show that the methods for analyzing the gaze data may vary in terms of processing, analysis, and scope of the data depending on the purpose of the virtual reality experiments. Further, they demonstrate the importance of what purpose statements are given to the subject during the experiment and the possibility of a technical approach being used for the interpretation of spatial information.

The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.

Resumo Este estudo propõe a realização de uma revisão integrativa da literatura a partir de artigos e publicações sobre o uso do “Primary Care Assessment Tool (PCAT)” como instrumento de avaliação desses serviços, discutindo os resultados encontrados no Brasil e em outros países do mundo, a partir da matriz inicial concebida pela equipe da Professora Bárbara Starfield e propor atualizações para a versão brasileira. Identificaram-se 124 trabalhos; porém, após a leitura dos mesmos, foram selecionados 42, de acordo com os critérios de inclusão estabelecidos. Deste subtotal, 17 (40,5%) foram estudos brasileiros. Sugere-se a necessidade da atualização de itens de cada atributo do instrumento, em particular do “acesso – primeiro contato”, incluindo novas formas de comunicação médico-paciente como: e-mail, mensagens por aplicativos em dispositivos móveis, uso de software de transmissão de vídeo para comunicação e mesmo utilização de telemedicina, entre outros. O PCAT apresenta simplicidade quanto ao uso, aplicação e cálculo dos escores, o que o torna útil e adequado para uso na gestão local dos serviços, especialmente em suas versões reduzidas em número de itens. Abstract This study proposes an integrative review of the literature based on articles and publications on the use of the Primary Care Assessment Tool (PCAT) as a tool for evaluating these services, discussing the results found in Brazil and in other countries of the world, from the initial matrix conceived by Professor Barbara Starfield’s team and proposing updates for the Brazilian version. We identified 124 studies, of which 42 were selected after full reading and according to the established inclusion criteria. Of this subtotal, 17 (40.5%) were Brazilian studies. There is a need to update items of each tool’s attribute, in particular “access – first contact”, including new forms of doctor-patient communication such as: email, mobile application messages, use of videoconference software for communication and even use of telemedicine, among others. PCAT’s use, application and calculation of scores is simple, which makes it useful and suitable for use in the local management of services, especially in its short version.

In an era of increasing pressure to publish and complete doctoral degrees as quickly as possible, all while managing heavy administrative workloads, it likely comes as no surprise that do-it-yourself (DIY) doctoral supervision tools are becoming increasingly prolific (Kamler & Thomson, 2008). Perhaps these materials are a response to a growing friction between time needed and time available for doctoral supervision, as well as between the crucial place writing occupies in a doctoral researcher’s life and the often tacit nature of apprenticing to become an academic. As both a doctoral student and a writing coach that works with other doctoral students, I am keenly interested in resources that can support me in both roles. Recently I picked up two texts to aid me with navigating my first attempts at publishing an article and with facilitating a doctoral writing workshop: Thomson and Kamler (2016), Detox your writing, and Paltridge and Starfield’s (2016), Getting published in academic journals. Both texts are geared toward a doctoral audience, though master’s level students and supervisors may equally appreciate the texts for their practical strategies. The texts are complementary as well. Where Thomson and Kamler focus mostly on the journey toward producing a dissertation, Paltridge and Starfield pick up from there to discuss how and why to consider publishing articles from the dissertation.

International audience; Violent pillar failures known as pillar bursts are suspected to be a possible cause of large collapses in underground mines. A classical stability criterion for mine pillars, based on the relative stiffness of the host rock and the pillars during their post-peak unloading, was proposed by Starfield & Fairhurst (1968) 6 and further demonstrated by Salamon (1970) 7. An energy balance indicates that an excess kinetic energy is generated when this pillar stability criterion is violated. The present study focuses on demonstrating how an explicit numerical modelling method may be used to calculate and locate the damping of this kinetic energy during pillar failure, considering simple 2D geometries. Arguments in favour of the validation of the numerical results are provided by comparison to analytical calculations and to an empirical classification of rockbursts proposed by Ortlepp (1997) 1. The good correlation between numerical, analytical and empirical approaches suggest that explicit numerical modelling of kinetic energy damping, following a procedure proposed in this paper, could be a useful tool for predicting zones submitted to a pillar burst hazard in underground mines and for consequently optimizing the mining method.

The core function of medical schools is to produce the doctors the nation needs1 and the NHS is clear that it now needs 50% of medical students to choose training for general practice. However, only 16.4% of newly qualified British-trained doctors seek postgraduate GP training.2 Moreover, one-third of British-trained doctors thought that their medical schools had not put them in a position to assess a career in general practice.3 I have met several junior doctors who have not heard of, let alone read, the writings of Professors McWhinney4 and Starfield,5 two world-class thinkers about general practice. GPs without understanding of the principles of their role have a shallower vision and often lower job satisfaction. How has this happened? When the NHS was established in 1948 many arrangements were made with the medical schools at a time when general practice was not a discipline and there was no professor of general practice in the world. The medical schools were initially entirely specialist led, linked to tertiary specialist hospitals with many special privileges. Training specialists was the priority and leading specialists, like Lord Moran, a Dean of St Mary’s Medical School, saw GPs as: ‘… having fallen off the ladder’.6 Professors of general practice came late to the party, first in Scotland in 1963, and in England in 1972. They were vigorously resisted by the Bristol, Cambridge, and Oxford medical schools, which appointed late in the 1990s. General practice/primary care struggled to gain entry to medical schools and even in 2017 …

The present article aims at discussing the singularities of primary health care (PHC) in contexts where violence, strongly supported by guns, is routinely, chronically, and systemically present, and to gauge the capacity of PHC as empowerment channel for communities where armed violence is an expressive vulnerability. Based on the Declaration of Alma-Ata and on the PHC principles described by Barbara Starfield, and focusing on community participation and social determinants of health, the discussion departs from the realities observed in Latin America and the commitment to access and universal coverage set forth in the third Sustainable Development Goal. The qualitative and quantitative characterization of armed violence and its consequences must be qualified using an intersectoral approach with heavy community participation in search of coherent and significant responses. The protection and safety of health care workers must be ensured to guarantee the continuous provision of health care services in contexts of violence.En el artículo se trata de abordar los aspectos singulares del trabajo de atención primaria de salud (APS) en los entornos donde la violencia, con el sólido apoyo del uso de armas de fuego, tiene una expresión habitual, crónica y generalizada, y de determinar la posibilidad que ofrece la APS de servir de canal de empoderamiento de la comunidad, donde la violencia armada representa una vulnerabilidad manifiesta. Con base en la Declaración de Alma-Ata y en los principios de la APS descritos por Bárbara Starfield, y con un enfoque en la participación comunitaria y en la perspectiva de los determinantes sociales de la salud, el debate tiene como punto de partida las realidades observadas en los países de América Latina y los compromisos orientados hacia el acceso universal a la salud y la cobertura universal de salud previstos en el tercero de los Objetivos de Desarrollo Sostenible. La caracterización cualitativa y cuantitativa de la violencia armada y de sus consecuencias debe hacerse a partir de un enfoque intersectorial con amplia participación comunitaria en la búsqueda de respuestas coherentes y significativas. También es preciso garantizar la protección y la seguridad de los profesionales para poder prestar servicios de salud de una manera continua en estos entornos.

Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models. Meanwhile, theoretic application informed by years of research on primary care provide insight as to what changes to expect and to monitor as practices consider DPC adoption.

In spite of its relatively young age, English for Specific Purposes is today quite literally the most global of language disciplines and exists, in some form or the other, in practically every country in the world.Research in the field is fecund, dynamic and diversified as befits a discipline that is intrinsically international, intercultural and interdisciplinary. Like Munby’s 1978 Communicative Syllabus Design, Hutchinson and Waters’ 1987 English for Specific Purposes: A Learning-Centred Ap...

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

The Starfield Summit crystallized key challenges and opportunities as primary care enters an era of value-based payment (VBP). New primary care models must reinforce Starfield’s core primary care functions while achieving the quadruple aim. Achieving these objectives requires pragmatic, rapid

It is said that in times of war old people bury young men. As we live in times of peace, and we are old, youngsters will need to bury us. It is said that we become good people after we die. But some of us were good before dying. They were good, generous and honored, wise and tender, effectively human. Some who passed away used to give us a cozy and protective shadow, and their absence leaves us unsheltered, alone with danger. A long time ago, one of our children asked to us: “When an old wise man dies, where does his knowledge and experience go to?”. We were not quite sure about the answer. “When this person has family and friends, they all learn from him. Thus, there will be a lot in their hearts and minds, and his/her kindness, culture, wisdom and accomplishments will be a part of memory, which will pass from generation to generation; it has been this way since the beginning of humanity. If this person diffused activities and work, whether written or illustrated, these will be his/her own words, and this person may be seen and revisited from time to time. Sometimes, words remain and we do not even know to whom they belong to, like Gilgamesh and his poem. Other times, authorship is neglected, even if we know who the author is, like Aristotle. And, other times, memory is alive and recent, like the work of Albert Einstein”. At that time, we did not think about it – but we do now – when a giant dies, we are left without a shadow. Barbara Starfield passed away, a giant in Primary Health Care (PHC), and her protective shadow abandoned us. She was a wise elderly woman, even though she looked young and looked like a student. Barbara Starfield had friends and family members who are capable of passing on her legacy of knowledge, kindness, culture, and wisdom, including many of her deeds and anecdotes. Barbara Starfield also leaves multiple registers, articles, books and presentations, which will serve as a path for others to go further. She was good, even before her death. Now, it is time for tributes, compliments and epitaphs, praised obituaries, and the public memory, which mixes the fear of death that writes its own show, and the desire to forget the mistakes of those who are highly appraised. Now it is time for tributes to death and for the dead. There was time for love, will, friendship, sharing, friendly respect; but many times, there was no time, and it is too late to go back and repair damages and mistakes. “To infinity and beyond”, say the grandchildren to their grandparents, asking them to push the swings harder. Others will come, and within the years, decades, centuries and millenniums, time will fade the memories of a giant, whose shadow no longer protects the dwarves (and this is how we are). Now we are aware of how small we were, exposed to the devastating environment of an arrogant Medicine, which despises everything it ignores, and it ignores almost everything. Now, we are aware of the damage we caused, and that getting a visa was a constant inconvenient for Barbara Starfield in her trips to Brazil. It would have been more worthy, and easier, to name her a Brazilian honorary citizen! We are aware of the damage we caused, and not little damage, when she was turned down at a doctoral examination board in Zaragoza (Spain) for not having a doctorate in medicine. It would have been more worthy, and easier, to name her doctor honoris causa! Now we are aware of her little impact on public health policy in USA, her home. Neither there is a “prophet” in his own land, nor a giant that shadows his close neighbors. It would have been much easier to take her recommendation and establish a strong PHC in her country’s health system, the less developed among the developed ones. Barbara Starfield was a leftist, always sensitive to the suffering of others and an activist against injustices. She met her future husband, who was also a medical student, in an act in favor of the Lincoln Brigade veterans, one of the international brigades that supported the Spanish Republic against the Nazi barbarism. She graduated as a pediatrician, and was a real cosmopolitan. She started her research on the organization of health services with KL White, master and friend, the one from the “medical care ecology” or “it is better to be approximately right than precisely wrong”. This giant accompanied her to the USA, just as other unique giants accompanied her to the United Kingdom, such as John Fry and Julian Tudor Hart. She had a positive critical attitude, pointed out the errors of a sanitary care based on experts, and showed its dangers (especially on her text about the medical practice as a preventable cause of death); with time, she developed an impressive theoretical foundation at the defense of PHC as the best response to excesses in Medicine and prevention. She knew how to analyze the excesses of a weak use of statistics, which was summarized in her article: “Internal elegance, external irrelevance”. She also knew how to compare countries, open paths, and respond to social and technological changes. She never forgot the impact of inequity on health. Many say her name in vain. Many justify barbarian actions on behalf of Barbara Starfield. There are many who confuse PHC with a solution that is exclusive to the poor, low-quality, and based on vertical programs. It is terrifying to think of the manipulation of her ideas by the ones who need them. It is no longer worth it to write things together to mark new paths, to claim for her work and her journey. Now, we have memories, the consolation of prayer in some synagogue, and the goal to follow the path that has been opened “to infinity and beyond”.

O Estado como provedor do bem público busca disseminar a saúde entre seus habitantes, sendo uma das principais formas de realizar isso é através da Atenção Primária à Saúde. Esse contexto contribuiu para o escopo deste artigo, cujo objetivo é verificar a eficiência técnica da Atenção Primária à Saúde no âmbito do sudeste brasileiro. Com uma abordagem teórica, tomou-se como base a literatura nacional e internacional sobre o tema, com autores como Mendes, Starfield, Ozcan e Salinas-Jiménez. Para o cumprimento de tal objetivo, utilizou-se uma abordagem quantitativa, através do modelo de Análise Envoltória de Dados (DEA). Os resultados apontaram para escores de eficiência técnica baixos, considerando os inputs e outputs selecionados para a região. O que oferece indícios de eficiência relativa baixa e por consequência, são importantes intervenções e ações pró-ativas na gestão da atenção primária à saúde. The state as provider of public health seeks to disseminate between its inhabitants, one of the main ways to realize this is through Primary Health Care This scenario contributed to scope of this paper, whose purpose is to verify technical efficiency of Primary Health in the Brazilian southeast. With a theoretical approach, was consulted authors such as Mendes, Starfield, Ozcan and Salinas-Jiménez. For compliance of this objective, employed a quantitative approach, using the model of Data envelopment analysis (DEA). Results showed low technique efficiency scores, considering the inputs and outputs selected for the region. What provides signs of relatively low efficiency and consequently are important interventions and proactive actions in the management of primary health care.

Clickstreams are visitors' paths through a Web site. Analysis of clickstreams shows how a Web site is navigated and used by its visitors. Clickstream data of online stores contains information useful for understanding the effectiveness of marketing and merchandising efforts, such as how customers find the store, what products they see, and what products they purchase. In this paper, we present an interactive visualization system that provides users with greater abilities to interpret and explore clickstream data of online stores. This system visualizes the effectiveness of Web merchandising from two different points of view by using two different visualization techniques: visualization of sessions by using parallel coordinates and visualization of product performance by using starfield graphs. Furthermore, this system provides facilities for zooming, filtering, color-coding, dynamic querying and data sampling. It also provides summary information along with visualizations, and by maintaining a connection between visualizations and the source database, it dynamically updates the summary information. To demonstrate how the presented visualization system provides capabilities for examining online store clickstreams, we present a series of parallel coordinates and starfield visualizations that display clickstream data from an operating online retail store. A framework for understanding Web merchandising is briefly explained. A set of metrics referred to as i>micro-conversion rates, which are defined for Web merchandising analysis in our previous work (Lee et al., Electronic Markets, 2000), is also explained and used for the visualizations of online store effectiveness.

In her landmark Lancet article ‘Is primary care essential?’1 Barbara Starfield described primary health care as being first-contact care that is comprehensive, coordinated, and continuous. To this could be added something about accessibility and effectiveness and, in the UK context at least, care that is provided locally and personally. In these changing times, most of these attributes of good primary care have come under pressure. Comprehensiveness can be threatened by inequalities in access, fragmentation of primary care teams, discrimination, and the effects of the inverse care law.2 Continuity is increasingly difficult to deliver, for well-rehearsed reasons, and coordination is often more of an aspiration than an achievement because of dysfunctional communication across the primary–secondary care interface. Finally, access, a crucial dimension of primary care, has become a political and professional battlefield in recent years. In last month’s issue of the BJGP Simpson and colleagues3 called for a policy rethink on access, and for a more nuanced debate to take us beyond the simple metrics of waiting times and capacity. This month, Access to Care is the major theme of the journal, with articles on the research evidence related to access,4 the controversy about 7-day NHS opening,5 and the persistent, pernicious influences of deprivation on equity and equality.6 The need for a more sophisticated discussion of access is emphasised by Campbell and Salisbury’s Research Into Practice article,4 in which they review the evidence on new opportunities to measure and improve access, as well as providing a useful model of the various factors and forces at play. Their careful review serves to show that the evidence base for much organisational thinking and policy rhetoric is based on very thin evidence or no evidence at all, although it is clear that good ideas may work well …

Two articles in the Ethics Feature of the current issue highlight the growing concerns with the validity of the biomedical literature and recommended guidelines for clinical practice. Genuis[1][1] and Abramson and Starfield[2][2] discuss the influence of commercial funding on clinical practice

Barbara Starfield’s research showed that investing in primary healthcare is the way to a successful health system. So why are these lessons not being heeded, asks Michael Caley, and will general practice commissioning help?

More time and provision of innovative tools to coordinate care may help Patients with multimorbidity often need more frequent general practice consultations, and more complex and structured care, than those with a single condition. Their care is often shared and needs to be coordinated with specialist community and hospital teams. A recent article in this series drew attention to the importance of having one main coordinator of care for patients with multimorbidity,1 and Starfield and colleagues highlighted, almost a decade ago,2 the challenge that primary care practitioners face in managing patients with multimorbidity more effectively. The standard primary care consultation for patients with multiple conditions needs to change, but how? Multimorbidity influences the general practice consultation in three main ways. Firstly, the amount of clinical information that must be collected for an individual patient with many different conditions can be extensive, especially when conditions and their stability change over time.3 Secondly, as conditions progress over time, management priorities and consequently information gathering, plans, and coordination of care must change.4 Thirdly, communication with other services involved in …

Building continuity of care takes work but earns trust Estimates of the prevalence of multimorbidity vary according to how it is measured, but studies agree that prevalence is rising and that it increases precipitously with age.1 By middle age, multimorbidity is the new normal. The first article in this editorial series on multimorbidity highlighted the difficulty of achieving evidence based targets for multiple diseases in a single patient.2 Treating all of a patient’s diseases optimally represents a considerable management burden for the patient and can result in a chaotic experience of care. Barbara Starfield defined relational continuity in primary care as person focused care over time, and such an approach is needed for patients with multimorbidity, rather than the more traditional one of managing diseases.3 But how can continuity of care be achieved for patients with multimorbidity? Continuity of care is most commonly defined as a connected and coherent series of healthcare events, or seamless care.4 For the healthcare professional, this means having all the necessary information about the patient at the point of care (informational continuity) and coordinating actions with other providers to deliver services in a complementary and timely manner along a recommended care pathway (management continuity). Connectedness matters for healthcare professionals because it translates into technical quality of …

The entry point for most people into any healthcare system is primary care. Not surprisingly, primary care–oriented disorders make up the vast majority of all medical conditions seen by healthcare providers. Starfield (1994) pointed out that countries whose health systems are oriented toward primary care achieve better health levels, higher satisfaction with health services among their populations, and lower expenditures in the overall delivery of health care. The American system relies heavily on both physicians as well as nonphysician clinicians to deliver primary care. In the US this cadre of providers includes doctors, PAs and nurse practitioners (NPs).

Barbara Starfield, perhaps the most influential figure in the primary care research community, died unexpectedly at home on June 10 this year while swimming in her pool. She was steadfast in her belief that primary care is central to the delivery of high quality cost-effective health care. Her second passion was as a champion of primary care as the key way to address healthcare inequalities, and she was founding editor of the International Journal for Equity in Health. She was highly critical of health care in her own country, (the US), viewing it as dominated by specialists who provide expensive, inequitable, and sometimes damaging …

I learned of Barbara Starfield’s sudden death from her husband, Neil “Tony” Holtzman. In his e-mail, sent at 2:43 am on Saturday, June, 11, 2011, Tony reported that Barbara’s absence from a simple act of nurturing, generosity, and generativity was the first sign that something was amiss—

Health services utilization has been the object of many books and papers in the literature. Measures associated with utilization are often a function of volume of services. The objective of this paper is to present a comprehensive approach to the evaluation of health services utilization and of associated measures, using databases. Based on the theoretical framework of Starfield (1998), we analyze health services utilization with the help of indicators that are not directly linked to volume but that indirectly provide an estimate, while also documenting the qualitative aspects of utilization. The indicators mark accessibility, continuity, comprehensiveness and productivity of care. Once the concepts have been defined, we propose their operationalization using the databases. We then present the advantages of multidimensional conceptualization of health services utilization through a simultaneous analysis of these indicators. Researchers and decision-makers in public health and health planning have much to gain from this innovative multidimensional approach, which presents a dynamic conceptualization of health services utilization based on health administrative data.This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(1): 11-18.

*School of Public and Environmental Affairs, Indiana University, Bloomington, IN 47405–1701, U.S.A., email meretsky@indiana.edu †P.O. Box 16426, Portal, AZ 85632, U.S.A. ‡Department of Environmental Science, Policy & Management, 151 Hilgard Hall, University of California, Berkeley, CA 94720–3114, U.S.A. §Wind Wolves Preserve, P.O. Box 189, Maricopa, CA 93252, U.S.A. **Grambling Cooperative Wildlife Project, Grambling State University, P.O. Box 841, Grambling, LA 71245, U.S.A.

The fact that strong general practice is an essential component of a high quality and cost-effective healthcare system is a message that has never been fully absorbed by successive ministries of health in the UK. (The over-worked and almost meaningless term ‘primary care led’ seems to have been used in the mistaken belief that it just meant cheap.) Ironically, it is a message that has been stated clearly in the US, where Barbara Starfield, the distinguished health services researcher at Johns Hopkins, has published high quality research to make the point1,2 and where Don Berwick, President of the Institute for Healthcare Improvement, wrote in his essay celebrating 60 years of the NHS that, ‘General practice is the jewel in the crown of the NHS. Save it. Build it’.3 We have done neither but instead, with the encouragement of the government, have half-dismantled it and sleep-walked into a time of peril for general practice and for patient care.4 Almost all of the core characteristics of general practice identified by Starfield are in danger of becoming eroded by successive and often poorly-informed lurches in health policy. General practice in the UK was never perfect — there was never an unalloyed golden age …

Background In the article by Starfield and colleagues, it was suggested that the concept of prevention has gone astray. This article aims to extend their ideas. Methods Our methods are to take the Starfield et al article and argue that it is possible and useful to see prevention in a wider context, going beyond prevention in healthcare and viewing prevention as a social good. Results This wider view results in some questioning of the nature of the benefits of prevention. At the same time, it suggests that the values of informed citizens might be more often elicited to help establish the principles underpinning the concept of prevention. Conclusion There is a need for further debate involving various disciplines to examine the concept of prevention in greater depth.

In this paper, we present MoStarD, a mobile application that couples starfield displays with dynamic queries to support user exploration of large datasets. A novel space compression technique enables users to compress areas of the starfield display to optimize screen space usage and easily focus on specific subsets of a dataset.

We want to thank Dr. Barbara Starfield for her insightful commentary about our paper in CMAJ May 26. While we agree with the issues she raised, her article contains a misleading statement that the higher rate of visits to emergency departments in capitation was observed only in rural areas. This

It is hard to figure out what motivated the comments on our paper “When There is no Doctor…” (McKinlay and Marceau, 2008), since Timmermans begins by characterizing our thesis as “bleak futurama,” proceeds to generally agree with much of our evidence and arguments and then concludes in almost complete agreement (Timmermans, 2008). He summarizes our essential position when he states, “They envision a world without primary care physicians but not necessarily without primary care.” We outlined seven reasons why primary care doctors are an endangered species, likely to be largely extinct by about 2025. We argue there will a continuing and likely increasing need for effective primary care, especially with a rapidly aging population and increasing co-morbidities, but this is unlikely to be provided by doctors. Social structural influences will drive them from the medical playing field (in contrast to their voluntarily “skipping town”) and they will be replaced by: a) eventually cheaper and equally effective health care workers (especially appropriately trained nurses), b) virtual visits on the internet (web visits), and c) specialists who replace primary care doctors and are part of the “hidden system of primary care” (Timmermans, 2008, PAGE REF NEEDED) (doctors trained as specialists who also provide general primary care to their patients). Admittedly, we gave insufficient emphasis to this phenomenon, even though it supports our general argument. We deliberately offer no judgment as to whether the likely disappearance of primary care doctors is a good or bad development – that requires careful consideration of the demonstrated effectiveness (preferably by randomized controlled trial) of doctors versus other types of delivery, say by nurses, specialists or even a computer. Lacking the requisite data we do not comment on whether the “the retreat of physicians is a loss for primary care.” (Timmermans, 2008, PAGE REF NEEDED) There is excellent observational evidence in support of the importance of primary care for population health, especially the landmark and often quoted work of Starfield and her colleagues (Macinko, Starfield, and Shi, 2007; Shi and Starfield, 2001). Whether doctors are the most effective, cost efficient and socially acceptable medium for the delivery of primary care remains an unanswered question; but it is amenable to resolution by careful evaluation. We acknowledged the ability of the medical profession to resist attempts to conduct trials of their comparative effectiveness and to discredit unfavorable results when they are eventually conducted. But in our view they will eventually be conducted – primary care doctoring vs “doctor nurses,” personal doctoring vs digital or web-based care, and doctoring vs walk-in minute clinics in large retail settings. The results of these studies will likely provide additional justification for the replacement of primary care doctors—nurses and retail clinics may prove as effective, more cost efficient and produce higher levels of customer satisfaction. Time will tell. Rather than focus on minor points in a commentary that generally supports our position, we take this opportunity to place Timmermans’ discussion in the context of more general concerns about current sociological thinking on doctoring and the medical profession. Medical sociologists appear afflicted with five types of blindness: they are 1) blind to the future; 2) blind to alternative theories and paradigms; 3) blind to current facts and recent developments; 4) blind to the magnitude of doctors’ discontent; and 5) blind to the technological advancements in primary care. Let us consider each type of blindness.

Due to advances in hardware technologies, mobile devices are increasingly capable of handling largescale data sets. While this development broadens the application scope of smartphones and PDAs, it also means that high information loads must be displayed on very limited screen real estate. A solution to this problem may be provided by starfield displays. Starfield displays maximize the data-pixel ratio by presenting data inside a zoomable 2-D scatterplot. However, a drawback is that once users have zoomed into the information space, they tend to become lost, due to the clipping of orientation cues. The chapter summarizes the research results of recent projects that were conducted to improve the navigation and orientation features of starfield displays on small screens. Several approaches, such as smooth zooming, overview window, and fisheye view, have been implemented and user-tested. The results may support interface designers when targeting mobile devices.

Coordination of care factors critically in patient safety and care quality across services and settings (Institute of Medicine 2001). The existing research focuses on coordination of care within a single institution, usually a hospital (Argote 1982; Baggs et al. 1992; Young et al. 1998; Gittell et al. 2000), or alternatively in an outpatient setting either by a single provider (usually a nurse, case manager, or primary care physician [PCPs]) or jointly between PCPs and specialists (Starfield 1998; Stille et al. 2005). This study expands research on care coordination through examination of postsurgical care involving multiple settings and multiple types of care providers. We examine surgical patients' experience of postdischarge coordination as they move from the hospital, often to a rehabilitation facility (RF), and then home. We hypothesize that patients' experiences of coordination problems are significantly associated with clinical outcomes and satisfaction. Increasingly there is an interest in extending coordination beyond the individual organization or care provider to encompass the whole episode of care for a given patient (Provan and Milward 1995; Shortell, Gillies, and Devers 1995; Gittell 2002). Having some form of external coordination between organizations has become an official mandate. Standards from Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and Condition of Participation from the Department of Health and Human Services hold organizations in which a patient receives care responsible for ensuring safe and effective transfers to the next setting (Centers for Medicare and Medicaid Services 2001; Joint Commission on Accreditation of Healthcare Organizations 2005). Despite these mandates, the process of coordination between institutions remains problematic. In a recent study between 15 and 72 percent of physicians reported problems with coordination across settings—lack of treatment follow-up, conflicting information from other care providers, delayed transfer of information following hospital discharge, and unavailability of relevant information during patients' scheduled visits (Audet et al. 2005). Starfield's review of research on coordination in primary care suggests that such communication breakdowns are not new (Starfield 1998). Starfield defines coordination as “the availability of information about prior problems and services and the recognition of that information as it bears on needs for current care” (Starfield 1998, p. 226), thereby distinguishing information transfer and information processing as separate components of coordination. This definition may be extended to specialty care and also to patients and caregivers, who, often serving as the primary conduits of information about their care, require information and must recognize important developments in order to seek and manage their care (Ellers and Walker 1993; Starfield 1998; Coleman, Maloney, and Parry 2005). For patients, coordination breakdowns, between providers or between themselves and providers, threaten continuity. For patients, continuity involves perceptions that providers have enough information about patients and their medical histories to make decisions about care (informational continuity); that providers, whether single or multiple, have a consistent care management plan (management continuity); and that providers who know them will provide care in the future (relational continuity) (Haggerty et al. 2003). Poor care coordination may result in conflicting information to patients and caregivers and lead to a loss of confidence in providers (Gerteis 1993). It may also produce confused, underinformed, or noncompliant patients, a particularly troublesome outcome when successful recovery depends upon patient cooperation (Ellers and Walker 1993). Additionally, coordination failures may produce patient dissatisfaction (Cleary 2003), which may have negative consequences for health care organizations in a competitive environment by reducing repeat business, generating negative word of mouth, or producing low patient care quality ratings.

This paper presents a qualitative and formative study of the uses of a starfield-based visualization interface for analysis of library collections. The evaluation process has produced feedback that suggests ways to significantly improve starfield interfaces and the interaction process to improve their learnability and usability. The study also gave us clear indication of additional potential uses of starfield visualizations that can be exploited by further functionality and interface development. We report on resulting implications for the design and use of starfield visualizations that will impact their graphical interface features, their use for managing data quality and their potential for various forms of visual data mining. Although the current implementation and analysis focuses on the collection of a physical library, the most important contributions of our work will be in digital libraries, in which volume, complexity and dynamism of collections are increasing dramatically and tools are needed for visualization and analysis.

This paper presents two palmtop applications: Taeneb City Guide and Taeneb Conference Guide. Both applications are centred around Starfield displays on palmtop computers - this provides fast, dynamic access to information on a small platform. The paper describes the applications focussing on this novel palmtop information access method and on the user-profiling aspect of the City Guide, where restaurants are recommended to users based on both the match of restaurant type to the users' observed previous interactions and the rating given by reviewers with similar observed preferences.