Search

In this study we investigate time experience in patients with depression and its susceptibility to visual stimuli in virtual reality. Participants wearing a head-mounted VR system that evokes the experience of flying through a virtual starfield while tracking the colors of the surrounding stars. In intervals of 8 - 18 sec participants have to report the currently predominating color and are asked to either estimate the duration of the past interval or report on their experience of passage of time in this interval. We study the effects of basic visual aspects of the stimulus (velocity and density of stars) and the duration of the interval on the two types of time experience. Furthermore, we test whether the judgments of duration of time or passage of time systematically differ between patients with major depressive disorder and healthy controls and whether the diagnostic groups significantly mediate the effects of stimulus properties on time experience. The experiment will be conducted in two blocks on two different days with each block only ever containing one type of time experience judgments.

In this study we investigate time experience in patients with depression and its susceptibility to visual stimuli in virtual reality. Participants wearing a head-mounted VR system that evokes the experience of flying through a virtual starfield while tracking the colors of the surrounding stars. In intervals of 8 - 18 sec participants have to report the currently predominating color and are asked to either estimate the duration of the past interval or report on their experience of passage of time in this interval. We study the effects of basic visual aspects of the stimulus (velocity and density of stars) and the duration of the interval on the two types of time experience. Furthermore, we test whether the judgments of duration of time or passage of time systematically differ between patients with depression and healthy controls and whether the diagnostic groups significantly mediate the effects of stimulus properties on time experience. The experiment will be conducted in two blocks on two different days with each block only ever containing one type of time experience judgments.

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

From studying the fossil records of stars to exploring the circumgalactic medium, UV astronomy is a field rife with scientific opportunity. CETUS is a proposed next-generation UV space telescope equipped with a suite of instruments tailored to the study of UV phenomena in our galaxy. To achieve diffraction-limited imaging and spectroscopy performance at short wavelengths, a high-performance and resolution optical design is necessary. We describe the telescope design options including a trade study between a traditional on-axis TMA and freeform off-axis TMA solution considering their alignment sensitivity and tolerances. Different secondary support structures are explored for the on-axis design to analyze the irradiance distribution of the point-spread function (PSF) due to the pupil obscuration and how it influences the simulated starfield at the telescope focal planes. With rigorous analysis we aim to enable the next spaceborne observatory for UV astronomy.

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.

This paper studies spillover effects from Starfield, a mega shopping complex in South Korea, to pre-existing, small retail shops over space, over time and across types of retail shops. Using the data on daily store traffics, we test for any complementarity or substitutability from Starfield to neighboring retail shops. Our analysis shows that spillover effects of Starfield on neighboring retail shops are equivocal in the short run. During the first year of the opening of Starfield, the contemporary effect (or the short-lived effect, lasting a single day) of Starfield is negative for consumer goods stores and personal service shops outside the 3-km radius, while it is positive for restaurants and bars within the 5-km radius. After that first year has passed, only the positive contemporary effect on restaurants and bars survives, and the cumulative effect (or the longer-lasting effect) turns significantly positive for consumer goods stores within 1.5 km of Starfield and personal service shops in the 1.5-to-3-kilometer radius. Our analysis estimates the temporal path of spillover effects—both contemporary and cumulative effects—from a newly-built mega shopping complex to neighboring retail shops, which is a novel contribution to the retail literature.

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.

This article describes a large-scale analysis of dissertation macrostructures in the Faculties of Education at five major Canadian research universities. We draw on van Dijk (1980) and Paltridge (2002) in categorizing the global organizational patterns of 1,373 PhD dissertations and cross reference these patterns with each study’s research perspective. Although prior research has addressed thesis and dissertation writing by drawing on ESP and EAP perspectives, the majority of these studies have focused on individual sections within the larger dissertation text, while little work has considered the macrostructures of these texts, with some notable exceptions (e.g., Paltridge, 2002; Paltridge & Starfield, 2007, 2020; Paltridge, Starfield, Ravelli, & Tuckwell, 2012; Thompson, 1999). No study to date, however, has analyzed the breadth of dissertation macrostructures covered in this project. This research therefore occupies an important space in describing current trends in dissertation writing and research approaches in contemporary educational research from five large English-medium Canadian universities. In so doing, we highlight not only the variety in dissertation writing and doctoral research but, more specifically, the emergence of two new hybrid dissertation macrostructures.

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...

Comprehensive primary care describes the long-term relationship between patient and provider in which medical services, support for self-care, and care coordination are the foundation. Research has associated comprehensive primary care with better system quality, equity, and efficiency. A performance measurement method is needed to enable teams delivering such care to optimize their performance and to evaluate the benefits over time. This article describes “The Starfield Model”—an approach to measuring quality, capacity, and total cost of care at this scope of service—and the results achieved by a small family health team in implementing this model. This experience suggests that real benefits arise from meaningful feedback to providers. The model has the potential to work in any payment system of primary care, thereby providing insight into all types of comprehensive primary care practices.

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”.

Due to changing population demographics and their state of health, the healthcare system in the United States is facing monumental challenges. For example patients suffering from chronic illnesses account for approximately 75 % of the nation’s healthcare-related expenditures. A patient on Medicare with five or more illnesses will visit 13 different outpatient physicians and fill 50 prescriptions per year (Friedman, Jiang, Elixhauser, & Segal, 2006). As the number of a patient’s conditions increases, the risk of hospitalizations grows exponentially (Wolff, Starfield, & Anderson, 2002). While the transitions between providers and settings increase, so does the risk of harm from inadequate information transfer and reconciliation of treatment plans. A third of these costs may be due to inappropriate variation and failure to coordinate and manage care (Wolff et al., 2002). As costs continue to rise, the delivery of care must change to meet these costs.

As Mackenbach (2006, p. 231) has pointed out, Britain ‘‘is now ahead of Continental Europe in developing and implementing policies to reduce socio-economic inequalities in health’’. However, after almost 10 years of initiatives from a Labour Government there are still no clear signs of a diminution of health inequalities (Department of Health, 2005). This is likely to be because it took the Blair government 4 years in office to start to reverse the widening trend in income differences and a further 4 years just to get back to the levels of inequality when they came to power (Brewer, Goodman, Shaw, & Sibieta, 2006). None of the dramatic increase in inequality during the 1980s and earlier 90s has yet been undone. Instead of reducing the underlying inequalities themselves, many policy initiatives have attempted to separate social and economic inequalities from their health consequences. But it has been a mistake to think that health inequalities can be substantially reduced even by well designed and targeted changes in policy which leave most of the society untouched. It would be nice to think that other countries could learn from these mistakes rather than repeating them.

Barbara Starfield’s paper on Pathways of Influence on Equity in Health (Starfield, 2007) is a timely call to scholars to consider the intricate webs of societal-level causal factors that can act independently and in concert to produce health inequality. The paper makes a persuasive case for avoiding simplistic, one-dimensional explanations for phenomena that are likely to be complex. The author presents a diagram reflecting the complexity of the conceptual framework, depicting multiple factors interacting with each other and across different levels of influence leading to inequality in health. I will comment here on just two of the many issues raised by this thought-provoking paper. Firstly, Starfield’s figure 1 is useful in calling attention to several different kinds of societal influences and to factors interacting within and across levels of influence. Another diagram depicting multiple levels of influence leading to social inequality in health was developed by Diderichsen and Hallqvist. The Diderichsen diagram depicts a cycle beginning with differences in social position, also referred to as social stratification—which I will define here as the categorization of people into different relative places in social hierarchies determined by economic resources, power/influence, prestige, and social inclusion. Examples of categorization by social position would include grouping

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.

The analysis by Barbara Starfield and colleagues has serious methodological and conceptual shortcomings. Despite the reference to “evidence” in the title, there is little evidence to guide the health care community or policymakers. The paper faults specialists for most of the ailments of U.S. medicine and fails to recognize the critical role of specialists in improving Americans’ health status. A variety of factors, including organizational and financing systems, discourage effective use of both primary care and specialty physicians. The nation would be better served by developing an evidence base on the relationship between outcomes and education, training, and specialty.

Barbara Starfield and colleagues present evidence that having more primary care physicians and fewer specialists per capita is associated with lower mortality rates. These analyses stand ...