ARTICLES (coNTINuED)
Delivery
of Health
Care
for Children:
Report
of an
Experiment
Joel J. Alpert, M.D., Leon S. Robertson, Ph.D., John Kosa, Ph.D.,1 Margaret C. Heagarty, M.D., and Robert J. Haggerty, M.D.
liWil ti’e Iainilij tlealtim Care Program and time Department of Pediatrics, Flart(zr(l .fcdical School, Boston,
.U(1SSL1(Il ti.sctts
ABSTRACT. This parer sulmimarizes an experiment
evaluat-ing the effectiveness of primmmary 1)ediatric care delivered to a
sample of low-inconme inner-cit families. Priniarv pediatric
care in this study was similar to pediatric group practice.
The stud findings indicated that theeffects of primary care
conmpared with the episodic care received 1w the control
families ‘ere appreciable. This included the decreasing of
hospitalizations, operations, illness visits, and appointment 1)reaking: increasing of health supervision visits, preventive
services, and latient satisfactions: and accomplishing these
changes at a lower cost. Patient morbidity was not altered.
Medicaid made no difference in the care patterns of the
experimental families amid apparently benefited only those
control families who were white. The controlled clinical trial
offers the best opportunity to compare different models of
primary care amid the data obtained can be used for planning
health services for children. Pediatrics, 57:917-930, 1976,
PRIMARY (:AISE, hEALTh SERVI(;ES RESEARCH, COMPREHENSIVE
(:ARE, LOW-INCOME FAM I LIES.
\Vhether different methods of delivery of
primary health services makes a difference to
patients is a subject of major importance and
continued debate. One reason for lack of
agree-ment is the limited research base presently avail-able. Decisions of enormous importance to
pedi-atnic care are being made with little regard for
what data are available. While there have been a
few controlled clinical studies involving children, the findings have l)een incomplete and
contradic-tory. These inconsistencies may be attributed to
differences in duration of the study,’ differences
in the populations studied,2 and different outcome measures used.
This paper is presented as a summary of one experiment which compared the effectiveness of comprehensive fam ily-focused pediatric care with pediatric care provided by hospitals and public clinics. An initial but preliminary report of the study findings appeared in 1968. Most of the
final data from this study may be found in detail
in the major study report.4 The data do not appear to be widely known among pediatricians,
although they are now being referenced in the
social science literature,3 The data suggest, as
(Received August 14; revision accepted for publication
October 29, 1975.)
Supported by grant H-74 from the Commonwealth Fund, US
Children’s Bureau, grant HSM 1 10-69-235 from the National
Center for Health Services Research amid Development, and
a grant from the Theodore Schultz Fund.
tDied July 1, 1972.
Dr. Alpert is now at the Boston University School of
Medicine amid Boston City Hospital; Dr. Robertson is now at
the Insurance Institute for Highway Safety, Washington,
D.C.; Dr. Heagart is now at the Cornell University School
of Medicine, Ithaca, New York; Dr. Haggertv is now at the
Harvard School of Public Health, Boston.
ADDRESS FOR REPRINTS: (J.J.A.) Department of
Pedi-atrics, Boston University School of Medicine, 818 Harrison
918 HEALTH CARE DELIVERY
have other studies,7 that there are definite advantages to delivering primary care to
inner-city families. For this reason, namely to call the
attention of pediatricians to the methods and
results of the experiment, this report is
presented.
A number of terms such as comprehensive care,
family care, and family-focused pediatric care
have been used to describe the health services
(independent variable) provided in this study.
These terms appear, at beast as commonly used, to have been replaced by primary care.
Primary care is defined within the personal
rather than the public health system, and is
focused on the health needs of individuals and
faniilies. Primary care is first-contact care and is
concerned with the factors which act at the
interface between the patient and the provider.
Primary care means longitudinal responsibility
for the patient regardless of the presence or
absence of disease. Primary care means
integra-tion of care for the patient and, when other health
resources are involved, the provider, whether
individual or team, retains the coordination role.
Finally, primary care, whenever possible, is
debiv-ered to families.
The primary care for this experiment was
designed to resemble, as far as possible, private
pediatric group practice. The model studied was
physically located in a small building, separate
from the barge hospital next to it, and arranged in a way as to resemble private physicians’ offices.
Each family in the experimental group had a pediatrician available, whether by phone or
appointment, including nights and weekends. The
physicians caring for the families were fellows
whose training program basted one or two years.
The physician provided care as part of a health
team consisting of physician, nurse, and social
worker. The services provided by the nurse
included triage and counseling, as webb as more
traditional nursing services. The social worker
provided counseling and social interventions. In
its organization, the program represented several
compromises between private practice and
deliv-ening medical care in the medical school and
teaching hospital setting. Proponents of primary care can object that the program was not truly comprehensive or that it was not complete family
care. Coordination of care of adults in the family who were usually seen elsewhere was difficult. Private practitioners can object that continuity of
physicians occurred only for a year or two at the
most. Nevertheless, the availability of a central
source of preventive and curative care as well as
social services, and a team involved in the social
and emotional as well as the usual health
prob-lems of the family, presented a significant
contrast to the episodic, fragmented, and
impersonal health care received by these families
before entering the program.
For the purposes of this study, a separate
medical care research unit was established. The
study design, the data collection, and the analysis
were accomplished without any involvement
with the clinical team. The latter provided
service and were responsible for the educational
activities of the program.
The experiment attempted to measure some
key outcome (dependent) variables which
resulted from providing primary care to children
in low-income families.
METHOD OF STUDY
In mid-1964, a sample of 931 low-income
families, with at least one child in the pediatric
age group but no regular doctor and living within
a three-mile radius of the program office, was
selected and divided randomly into three groups
of equal size. The study design is noted in Table I. This sample was poor (25% were on welfare) and the employed had a median income of $4,300; there was substantial m inonity representation (40% were black). There were no
Spanish-speaking families.
From the 750 families, 250 were randomly
selected as the experimental group and were
offered the experiniental care package. In order to observe and to measure changes in health and in the use of health services that could be
attributed to the experimental intervention, the
experimental group was compared with the
remaining 500 families of the sample who were the controls. No primary care was offered to the control families and they were expected to continue to use their previous care sources.
For the purpose of learning the effects of the
data collection process, the 500 control families
were also divided into two groups. One half of
them (contact controls) were, together with the
experimental group, approached every six months
and, using the mother as the regular source of
information, interviewed on the health of the
family and their use of health services.
The third group of 250 families (noncontact
controls) was interviewed briefly in 1964 and not
contacted again until 1968, when, at the close of the data collection, they were interviewed
together with the other two groups of families.
This design was to control for the possible effects of repeated interviews which could lead to
Experimnental group
(No. = 252);
comprehensive
care offered;
semiannual
in-terviews; final
No. = 173
Control group (No. = 261);
semniannual in-terviews; final
No. = 189
Preventive Services
differences were noted between control groups
and the data on the noncontact control group are
not presented in this paper.
RESULTS OF THE STUDY
The final comparisons are based upon 173
experimental families and 189 control families
who continued to participate in the study to the
end of the three-year study period. The
experi-mental and control groups were compared on all
preexpeniniental variables. There were no
signifi-cant differences found in those families lost from
the study and those who continued. In addition, a
special study indicated that with intensive effort
75% of the lost families in the experimental group
could eventually be enrolled in the program and,
once enrolled, behaved no differently than the
original enrobees.’ Thus boss from the study did
not bias the comparability of the groups.
Data Collection
Interview information was obtained from the mother and included at least four sets of data, providing several measures of similar informa-tion.”’2 (1) In the preexpenimentab and
postex-perimental interviews, that is, in 1964 and 1968,
the mothers were presented with a Child Health Index, an instrument patterned after the Cornell
Medical Index for adults, and were asked to check
for each child separately whether he or she ever had any of the complaints listed. Detailed
infor-mation on utilization, knowledge, and attitudes
were collected. (2) In semiannual interviews, the
mothers were asked to indicate the incidence of
illness experienced by any member of the family
during the preceding six months, as well as any changes in the data base. (3) Also at six-month
intervals, the mothers were asked to keep a
28-day diary of all symptoms, upsetting events, and
related actions taken in the family.” (4) In the
postexperimental interviews, data were obtained
on sickness days and drug days experienced by all
family members within specific periods, in
addi-tion to repeating almost all of the questions asked in the baseline interviews.
Morbidity
There is no standard definition of morbidity which is universally acceptable. Individuals and
families vary considerably in their perceptions of illness while the physician’s definition of illness is
usually based on traditional history, physical
examination, and laboratory tests.
Perhaps the best way to have measured morbidity was through the use of medical records.
TABLE I
THE SAMPLING DESIGN
Emergency clinic population (No. = 4,327 families); 3,346
ineligible amid 50 refusals left 931 eligible for study
Active eligible group (No. = 674);
two home interviews; loss of 161 families
Noncontact
con-trol group (No. = 257);
interviewed at
emmiergency
clinic; reinter-viewed during final study pe-nod; fimial
No. = 180
But in a city families use several medical facilities and each of these facilities has a separate and, as a result, incomplete record of the same individual. Therefore, the first task was to find the medical records to review. An attempt was made to match the records of the two large Boston hospitals where most children went for acute care for a subsample of 30 families who were identified as having used both hospitals. After considerable effort only 45% of the 102 children involved could be matched, in almost 40% of the cases the match was uncertain, while in 15% of the cases the second hospital had no record of the child.
Because of these difficulties, only limited use of the data from medical records was attempted. Most of the study data came from the interviews with mothers on the assumption that the mother
is the principal manager of the family’s health.
No evidence was found in any of the
instru-ments of a consistent and significant difference in
morbidity between the experimental and control groups. The evidence remained the same when
the children were compared by age groups and by categories of complaints and illnesses.
From this study, like others,1’ it appears that
primary care, when compared to the fragmented
but technically competent care usually received
by the urban poor, did not improve the short-term
health of its recipients. Conversely, there was no evidence that the children in the experimental group were less healthy for having received primary care.
#{176}Basedon the number of children living at home during the given six-month period which, imi each group, is always over 550 childremi.
TABLE II
SELECTED PREVENTIVE MEASURES FOR CHILDREN AS REPORTED BY MOTHERS AT THE END OF THE EXPERIMENTAL PERIoD
Preuentiee Measure
Experinien
.V.#{176}
((11 Group
#{176}At
Coimtrol Group
No. #{176} %t P
Fluoride drops or tablets 609 30 689 1 1 < .001
Tuberculin test within last year 606 70 682 47 < .001
Immnunization begun (under age 1 yr) 16 88 22 59 < .1
Completed imnmnumiization (age over 1 yr) 593 97 67094 < .05
Completed polio series 602 91 680 88 < .1
Measles vaccine (those without natural measles) 236 71 296 57 < .01
Tetanus booster within last 5 years 387 92 410 81 < .01
Smnallpox vaccination within last 5 years 510 55 554 44 < AX)1
#{176}Nimmnberof children varies from omie item to the next because some items were miot applicable to all children or because an
occasional mother failed to answer the question.
tPercentage of children in cacti preventive category, not percentage of total numimber imi each group.
primary care. At the end of the experimental
period, in 1968, the mothers reported consistently higher rates of preventive measures in the exper-iniental than in the control group (Table II).
Nearly one third of the experimental children had
received fluoride but only slightly more than one in ten of the control group had done so (fluoride is
not available in the Boston water system). Over two thirds of the experimental children had had a
tuberculin test in the last year compared to about
one third of the control children. Although
chib-dren over 1 year of age showed little difference
between experimental and control groups on
completion of immunizations, infants in the experimental group were considerably more
TABLE III
H05PmTALIzATI0N AND SUmu,m:AL OPERATION RATES BY Smx-MONTH PERI0ns#{176}
IIospitaliz(ltion for All Cases per 100 Children
Operation Only per 100 Children
Time Period
Experi-mental Control
Experi-mental Control
(mo) Group Group Group Group
0 to 6 4.3 2.0 1.6 0.5
7 to 12 3.0 3.7 0.8 1.6
13 to 18 1.8 3.3 0.8 1.2
24 1.9 3.6 1.0 2.0
25 to 30 3.0 3.9 1.3 1.9
31 to 36 i4 3.5 2.0 2.0
likely to have begun iiiiniunizations. There was
little difference among the groups in completion
of the polio series or reception of tetanus booster
within the last five years; almost nine of ten
children in both groups had completed these
measures. Over two thirds of the experimental
children had had measles vaccine, but only about
60% of the control group; 55% of the children in
the experimental group had had a smallpox
vacci-nation a.s against slightly over 40% in the control
group at a time when smallpox vaccination was
still medically recommended. It should also l)e noted that according to current recommendations
some of the experimental children were
over-immunized while others were not fully reached.
Thus, children who were vaccinated against smallpox were placed at “risk” as were those who
received unnecessary inim unizations against
diphtheria amid tetanus.
Utilization Patterns
The patterns of using medical facilities (clinics,
hospitals, physician’s offices, etc.) was measured.
Visits to physicians or clinics, either for illness or
check-ups, hospitalizations, and operations were
ascertained from the diaries and questionnaires. A
quantitative analysis of the medical records of all
patient contacts with the Children’s Hospital Medical Center, Boston, was also accomplished.
Since the experimental families used this hospital
more often than the control families, the hospital records of the three groups could not be directly
compared in the number of hospitalizations amid
outpatient visits, but they were compared on the
TABLE IV
MONTHLY RATES OF VISITS TO PHYSICIANS BY SIX-MONTH INTERVALS
Time Period
Health Supervision Visit Rate per 100 Children
Illness Visit Rate per 100 Children
Total Physicians Visits Rate per 100 Children
Erperimental Control Erperinmental Control Experimental Control
(rimo) Group Group Group Group Group Group
Preexperimnental 5.2 6.2 23.0 21.7 28.2 27.9
6 12.3 4.2 15.9 21.4 28.2 25.6
12 7.3 2.1 10.0 17.8 17.3 19.9
18 8.3 6.8 13.4 19.1 21.7 25.9
24 8.0 4.0 15.1 16.6 23.1 20.6
30 8.7 5.7 17.7 19.8 26.4 25.5
36 5.3 2.9 17.1 21.2 22.4 24.1
Table III sums up the comparative hospitaliza-tion and surgical operation rates by six-month
periods of study. When hospitalizations for all causes were examined, the control group showed
a steady rate with the exception of the first six
months. This difference may be related to the
intake process and may represent catch-up. In the
experimental group, the hospitalization rate
decreased from 4.3 to 1.9 per 100 children for
each six-month period over the first two years,
and then increased in the third year, reaching 3.4
in the last half year. Except for the first period, the experimental group had lower hospitalization
rates than the control group. When
hospitaliza-tion for surgical procedures was examined, the
same trends and differences appeared. The
hospi-talization rates of experimental and control
groups converged in the last time period of the study, but the overall hospitalization rate for the
three years was significantly lower in the experi-mental group. One additional finding was that hospitalizations, when they did occur, consumed
15% fewer hospital days in the experimental group compared with the controls.
The physician’s better acquaintance with the
patient families, as in private practice, can lead to
reduced hospitalization rates and to the
elimina-tion of some unnecessary or preventable hospital-izations. Specifically, the physician who has never
seen the child or mother is more likely to hospi-talize the child when in doubt and the threshold of doubt is high. Physicians in the primary care
program could decide not to hospitalize or to
recommend against surgery when the issue was in
doubt. The physician knew that the decision was
not irreversible; the situation could be reassessed
through follow-tip with the family, as in private practice. In addition, certain types of elective
surgery (circumcision, tonsillectom ies, umbilical
herniorraphies) were discouraged in the experi-mental program. The reduced hospitalization rates were achieved without any measurable detriment to the children in the experimental
group, who, as previously noted, had the same
level of morbidity as the control children.
Another important utilization measure is the pattern of visits of physicians. This analysis must
distinguish between health supervision and illness visits. Although currently tinder review, there is
some consensus as to the desirable number of health visits specified by the age of children but no similar rules govern the appropriateness of
illness visits. The impact of the program on both
health and illness visits to physicians is summa-nized in Table IV which shows rates of visits, both for health supervision and illness, in every six-month period.
The data indicate that in the preexpenimental period (the summer of 1964 when the first health calendar was administered) the experimental and control groups had similar rates of health and illness visits. At the end of the first six months the rate of health supervision visits per 100 children
more than doubled. This can be attributed to the effect of the intake period when a large number of health visits were scheduled for enrollment purposes. Subsequently the rate of health visits decreased but remained at a consistently higher level in the experimental group. In the control
group the rate of health visits showed a wide fluctuation from a low of 2. 1 to a high of 6.8 per 100 children six months later, but during the whole experimental period the rate of the control group was consistently bower than in the experi-mental group.
TABLE V
922 HEALTH CARE DELIVERY
RATE OF BROKEN APPOINTMENTS IN ILLNESS FOLLOW-UI’ VISITS BY Smx-MoNimI PEluous
Lxpenmental Group
No. of
Clink- Control Group
X(). of
il11l(’ Periods (iizo) Appointments O/ Brokeit Appoimitinents % Broken
0 to 6 192 13 232 38
7 to 12 248 25 172 38
13 to 18 289 12 150 38
19 to 24 265 18 1:32 48
25 to 30 209 11 146 32
:31 to 36 222 35 108 35
health visits in each age group of children, it is
possible to compare the standard and the actual performance of the sample. This comparison was
made for the third year of the experiment. It indicated that the experimental group received
about 70% to 75% of “optimal” health visits,
while the control group received only about 40% to 50%. Generally speaking, in the experimental and control groups, infants in the first year of
their lives were most likely to realize the standard
and the discrepancy between desirable and actual
performance increased as the age of the children increased, particularly in the control group.
An examination of the illness visits (Table IV)
shows a different change. In the control group the
rate of illness visits demonstrated narrower
fluc-tuations and stayed very close to the preexperi-niental level. In the experimental group,
however, the rate decreased substantially, and, in spite of minor fluctuations, stayed at lower levels
during the experiment, although bess so toward the end.
The most likely explanation for the differences
in illness visits was the use of the telephone which
substituted for illness visits in the experimental
‘: Telephone contact often proved
ade-quate to handle problems, niaking actual visits
unnecessary. For most of the control group there was no regularly available telephone consubta-tion.
Thus, it appears that the experimental care reduced the rate of illness visits but increased the
rate of health supervision visits. The sum of health and illness visits remained similar for the
experi-mental and control groups (Table IV). This
mdi-cates that primary care with increased health visits did not place a greater burden in the system
as far as the total visits to physicians were
concerned.
Studies of physician visits must also include
appointment-breaking which is common in the
institutional setting. The high frequency of
broken appointments is usually explained by the
impersonal and discontinuous relationships that
prevail in these clinics. ‘ Only limited
conipari-Sons of broken appointments can 1)e made within the sample. The control group had no regular
health visits scheduled that could be studied and
therefore only the illness follow-tip visits could be
compared as they occurred at the comprehensive clinic for the experiniental group and at the
emergency clinic at the back-up hospital (Table V). The control group received only part of its illness care at the emergency clinic and had
consistently fewer follow-tip appointiiients
sche-dubed than the experimental group.
The overall percentage of broken
appoint-nients shown by the control group was similar to
the percentage of broken appointments by nonstudy patients at the emergency clinic controlling for diagnosis. In the experiniental group the percentage of broken appointments
fluctuated from a low of 1 1% to a high of 35% in the final six-month period, and there was a predictable pattern in this fluctuation (Table V).
Broken appointments were less frequent in the
first six months of any given calendar year and
more frequent in the period froni July to
Decem-ber. Physician turnover, occurring in July of each
year, and patient vacations may have influenced
this trend. In the control group, broken appoint-nients fluctuated slightly between 32% and 38%,
with the exception of an unexplained jump to 48% in the fourth period of study. On balance, the
experimental group averaged about one half of
the broken appointment rate of the control
group.
In the last six months of the experiment, the
proportion of broken appointments rose to 35% in
same prOI)ortion as Ol)selVed in the control group. Examination of the data on hospitalizations (for
all causes and fom surgery) as previously noted and in illness visits to physicians showed a similar
trend (Tables III, IV, and V). From the 7th to the
1:3th month of the three-yeai experiniental effoit there were fewer broken appointments in the
experimental than in the control group. Howevem, during the final six months the differences
between the control amid experimental groups
diminished. This raised the possibility that the
changes attmibuted to primary case in this study
niay be only temporary. This issue will be discussed in the section on disengage muemit.
Health-Related Attitudes and Patient
Satisfaction
Is it possible that experience with primary care
changed health-related attitudes? Was the
experi-eiice with primary care satisfactory for the
patients?
One set of questions assessed the mothers atti tude toward preventive practices, her general
attitude toward physicians, and her attitudes
toward the relative importance of health. The
scales, together with attitudinal questions
de-signed to measure alienation, acceptance of
maternal role, and authoritarianism
,
wereincluded in the three questionnaires admiiinistered
in 1964, 1966, amid 1968. A comparative
examina-tion of the scales as well as single items indicated that both the experimental and control group
were originally similar on the health-related and other measured attitudes, and no meaningful and
consistent change in any of the attitudes occurred between 1964 amid 1968.’
The experimental program aimed to change the relationships between the health team and
patients, to replace the impersonal relationships
of the hospital with the personal relationship
essential to primary care. Since it was not possible
to observe the actual interaction between health
teani members and patients, without interfering
in the interaction, a number of questions were
asked about these relationships. Therefore, the
first interview iii 1964 asked whether the family
“had a usual doctor who takes care of the
children.” At that time, of course, none (an
eligibility requirement) answered yes. The ques-tion was repeated in the closing 1968 interview
and 69% of the mothers in the experimental group
and 33% in the control group answered in the
affirmative (P < .001).
In order to assess the mode of contacting
physicians, the mothers in 1968 were asked what they would do in case their child had an acute
illness. “Telephone to a doctor” vas one of the
answer categories and this was checked by 84#{176}/oof
the experimental mothers amid l)y 65’ of the
control niothers (P < .001). Iii the contmol group
:32% of the mothers had no ustLal physician and
these, plus the :3:3% h the course of the stud who obtained a physician and who weme vi1ling to phone iii case of acute illness. undoubtedly
reflected the increased utilization of private
prac-tice physicians following the introduction to Medicaid in Massachusetts which occurmecl
approximately in idway during the experi n ient.
To learn about satisfaction, the mothers were
asked how satisfied they were with cam-c they
received at theii most recent tuedical visit and were asked to select from among various
alterna-tives whether their visit was satisfactory or
unsat-isfactory. Table VI displays the percentage of
niothers who were satisfied or dissatisfied with
specific elements of the visit such as waiting time, time with the physician, ease of talking with the physician and muse. and exactness of the diagno-sis. The greatest difference between experimental
and control groups occiirmed around the issue of
waiting time. Over 60% of the mothers in the
experiniental group but only 40% in the control groups were satisfied, while, conversely, more
than 20% in the control group but only 6% in the experimental group were dissatisfied with waiting time. In addition. mothers in primary care also
found the professional relationships more
satisfy-ing amid significamitly niore of them thami control
niothers imidicated ease in talking to the
physi-cians and nurse. The groups did not differ signif-icantly concerning sufficient time givemi by the
doctor.
Imi 1966, at about the miiidpoint of the
experi-nient, au unobstrusive time-motion study of patients was carried out. Fifty patients were chosen at ramidom iii the experimental care climiic
and 50 in the emergency clinic of Children’s Hospital. A trained obsemver followed the selected
patients from the timiie of entramice imito the clinic
to the timiie of departure and recorded on an
observation schedule the time the patiemits spent
in various activities. The analysis of data showed
that after emitry to the clinic the patients spent an average of seven minutes in the waiting room in the primliary care clinic as against an average of 35
niimiutes ill the emiiergency clinic (P < .001). After
entering the examining roomui, the patient waited ami average of nine minutes in the emergency
clinic before the physician actually emitered amid
Erperimen (a! Group Con trol Group
- Mothers’ Reactions (.Vo. 1 73) (Xo. = 189) P
Satisfied
There was mio waiting 60.8% 38.2% .001
Doctor gave enough time 86.6% 82.0% NS
Doctor was easy to talk to 87.7% 75.7% .01
Nurse was easy to talk to 68.4% 54.0% .02
Doctor explained exactly what the trouble was 74.9% 81.0% NS
Dissatisfied
Wait was too long 6.4% 23.2% .001
Doctor did not give enough time 2.3% 5.8% NS
Doctor was difficult to talk to 1.8% 9.0% .02
Nurse was difficult to talk to 1.8% 3.7% NS
Doctor did not explain what the trouble was 2.9% 5.3% NS
in the emergency clinic before being seen by the Satisfaction with medical care is important as a
physician. goal because it has major consequences in the
The length of face-to-face comitact with the miiedicab care process. Compliance with a pre-physician averaged 19 minutes in the primary scribed regimemi has been repeatedly related to
care climiic amid 15 minutes in the emergency the degree to which the patiemit is satisfied with
clinic, a difference that could have occurred by the physiciami-patient ‘
chance (P < .09). When the actual contact time
was conipared to the waiting time, it appears that
imi the primary care clinic the patients spent about COS 20% iiiore time with the physician than in waiting T
for himn, but in the emergemicy clinic they spent At a time when medical costs continue to rise 3.5 times as much in waiting as in seeing the more rapidly than the national economy gener-physician. These data suggest that the mothers ally, the issue of cost is especially relevant. were more satisfied with those aspects of the care Primary care, as practiced in this study, placing received where objective observations showed the emphasis on the use of the health team and there were in fact greater differences. dealing with social-emotional problems, required
TABLE VII
AVERAGE LABORATORY AND DRUG CHARGES PER DIAGNOSED ILLNESS: FIRST VISIT
Lxpcrunen tal Group Clin ic Control Group
Diagnosis \‘o. #{176} Charges Vo. #{176} Charges
Upper respiratory tract imifection 326 $1.95 213 $5.34
Otitis media and extema 304 $4.84 248 $7.21
Tonsillitis and pharngitis 255 $3.04 202 $5.00
Streptococcal disease 102 $4.76 62 $4.99
Pneumnonia 30 $14.17 28 $26.64
Astlinia 25 $4.92 38 $12.58
Other respiratory diseases 80 $3.38 45 11.40
Gastrointestinal problems 128 $2.16 101 $5.10
Traumiia 288 $3.30 3X) $5.97
Measles, chickenpox, mumps, etc. 142 $1.41 80 $5.04
Skin problemns 223 $2.41 150 $2.57
-19 $5.95 26 $11.00
TABLE VI
924 HEALTH CARE DELIVERY
Genitourinary problems
#{176}Nuimiberof diagnosed cases.
TABLE VIII
FREQUENCY OF OBTAINING CULTURES: FIRST VISIT
Diagnosis
Experimen
#{176}
((11 Group
(0
Clinic C’ontrol Group
-.Vo. %0
Upper respiratory tract infection 326 28.8 213 59.6
Otitis miiedia and externa 304 12.2 248 25.8
Tonsillitis amid pharyngitis 255 86.7 202 86.6
Streptococcal disease 102 92.2 62 67.7
Pneumnomiia 30 40.0 27 44.4
Asthma 25 8.0 38 23.7
Othem-respirator_diseases 80 13.8 45 35.6
Gastroimitestimial problemns 128 17.2 101 40.6
Trauma 288 10.4 390 3.3
Measles, chickemipox, mumps, etc. 142 43.0 80 47.5
Skin problemns 223 9.9 iSo 16.0
Genitourimiary problems 19 36.8 26 57.7
#{176}Perceiitage of children imi each diagnostic category, riot percentage of total nunil)er imi each group.
more work and time on the part of the personnel, and, thus, higher costs. At the same time, the
provision of preventive and curative care in the
samiie facility should be cheaper because of the reductiomi in duplication of facilities and
person-nel. Costs were obviously lowered by fewer and
shorter hospitalizations. The increased cost of
health visits was equalized by reducing the
sick-ness visits.
Other cost data, vhicli were comparable between the primary care clinic and the emer-gencv clinic, were the data on use of laboratory
and drugs imi the two settings. These data were
obtained froni the quantitative review of muedical records for the children in the samiipbe. From these records, the essential characteristics of the visit-such as location, nature and type (illness vs.
health), serial position (initial vs. follow-up), labo-ratory tests, diagnosis, treatment-were coded for
the three years of the experimiient. Then for each
visit the overall charges for laboratory and
radio-graphic tests as well as drugs were calculated
umiiformly at the standard hospital rates,
disre-garding whether the family did or did not pay for
themii.
The data made it possible to compute the average laboratory and drug charges for the
experimiiental amid control patients for diagmiosed
illness categories. Table VII presents the results
for imiitial acute illness visits. In each of the 12
illness categories the charges were consistemitly less in the experimental clinic thami in the emer-gency clinic. Imi some categories (e.g., “other respiratory diseases’ ‘; “measles, chickenpox,
mtmmps’ ‘) the charges in the experimiiemital climiic
were about one third of the charges in the
emergency clinic, in other categories (e.g., “tipper respiratory tract infectiomi’ ‘; “asthma”) the former
was omie half of the batter.
The freqtmency of usimig antibiotic therapy was
comiipared for the groups by the 12 illmiess
catego-ries. The results, not presented in any table,
indicated that the differences between the groups were sniall and not significamit.
The source of the differences iii charges was in
different use of the laboratory.’’ To illustrate, the data on cultures and X-ray are presemited in Tables VIII amid IX. In six illness categories (tipper
respiratory infections, otitis, asthma, other respi-ratory disease, gastroimitestinal, amid skin
prob-lemiis) ctmltimres were taken omie half as often or
even less frequently in the experimental than in the control groups. In two additional categories
(
pneumiionia and genitourinary problemus) theexperimental group had soniewliat lower
percemit-ages. In tonsillitis and pharyngitis there were
practically identical percentages of cultures,
while in two disease categories (streptococcal amid
traumiia) niore cultures were obtained in the
experimental thami in the control group. The total
effect was that cultures were used less often in the
primary care clinic than in the emiiergency
clinic.
The frequency of using X-ray studies, as noted in Table IX, was consistent with the findings on
cultures. In every illness category, the
LxperiiimCO (0! Group
(1,;, 0
326 0.9 213 7.0
304 0.3 248 .2
255 0.8 202 2.5
Streptococcal disease 102 0.0 62 1.6
Pmieunionia 30 30.0 28 96.4
Asthma 25 16.0 38 39.5
Other re5piratOr diseases
Gastroiiitestimial pro1)lem1s
80 6.3 45 31.1
128 1.6 101 3.0
Traummma 288 16.0 39() 27.4
Nleasles, chickenpox, mummips, etc. 142 0.7 80 7.5
-Skimi_prol)lenis 223 0.4 150 0.7
Gemiitourinary prOI)leIlis 19 0.0 26 7.7
TABLE IX
CARE DELIVERY
FREQUENCY OF OBTAININ(; X-RAvs BY ILLNESS: FIRST \ISIT
Diagnosis
1PP, respiratory tract infection Otitis media amid externa
Tonsillitis amid pharymigitis
‘Percentage of children imi each diagnostic category, not percentage of total numnber in group.
Clinic Control Croiip
\o.
An amialysis of the follow-up visits for the same illnesses was also domie. The administration of
diagnostic tests was generally less frequent in
follow-tip visits and the differemices between the
experimriemital amid comitrol groups were not as large as at the first visits, btit contimitied to be lower in
the experiniental group. Ftirtherniore, the ntini
-ber of follow-tip visits relative to the ntimber of
first visits was lower in the experimental than in the control groups. Thus, the differences in the tise of diagnostic tests fotmnd at first visits cotild
miot be attributed to delay by which physicians in the primary care clinic postponed the use of stich
procedures until a later visit.
It is well recognized that residents imi the
emergency clinic followed a philosophy of “safe-ty,” and operated on the principle that the
patient niay never be seen again at the clinic or,
at any rate, riot by the samiie physician. Therefore,
they were likely to obtain a ctilttire or X-ray at
the first visit for an illness. The physicians at the
experimental clinic, relying on their relationships
with the families, again, as in private practice,
temided to order ctiltures or X-rays in more limited situations. For example, in the experimental
clinic diagnosing and treating pneumonia without
obtainimig an initial chest X-ray was an accepted
practice as was not ordering a skull X-ray
routinely for head tratimiia.
The differences in cost and in practices are
important. Of the many factors considered,
ther-apeutic philosophy has already been mentioned. This philosophy in its practical application is
closely related to instittitional policy. The
emer-gency climiic is part of a teaching institution where
learning experience and “scientific certainty”
boomii large. Any physiciami qtiickby learns from the question of his attending or supervising resident
who asks, “Did yoti get X test on this patient?”
Contimiuity of care was a major factor affecting
the use of diagnostic procedures. In the
emer-gency clinic the physician saw patients who, as has been previously noted, he had never seen
before and did not expect to see again. In primary care, the physician knew the family. He could
obtain additional knowledge from other miiembers of the health team and he had access to more coniplete medical data. He was acqtiainted with faniily dynamiiics, health problems of siblings, and
parents as well as the mother’s reliability in
reporting symptoms and seeking medical aid.
Aided by stich knowledge, he cotild reach
diag-nostic and therapetitic decisions with fewer labo-ratory procedtires.
The evidence leads to the conclusion that the
policy of pnimliary care, contintiity of relation-ships, amid the use of the health team are factors beading to redticed hospitalization, fewer illness visits, and lowered use of laboratory facilities. At
the same tinie, however, the overall cost of the two types of health care could not be established. Overhead costs (not analyzed in this experiment)
show great variations by types of patients and
instittitions. In view of this, the hypothesis that primary care, especially outside the hospital, is very likely less expensive than the fragmented
and episodic health care that low-income families
RELIANCE ON PRIMARY CARE
Comiipreliensive clinical services weme offered to the experimental group in the expectation that
the primary care program would develop into a central source of care for the children involved. It was expected that by the cud of the study the experimental faniilies wotild rely heavily on the primary care prograni for their children’s medical services; jtiSt as most families receiving private care tend to rely on one major source, namely theii physician, while the control grotip wotild
show the same kind of fragmented care as observed at the beginning.
One important change was not anticipated at
the time the study began. This was the Medicaid legislation of 1966 which enabled eligible low-incomiie families with children, to use, if they elected to do so, private practitioners as their regular sources of pediatric care. Medicaid, by removal of the financial barrier, helped to reduce the reliance of poverty families on hospitals and public clinics.
At the beginning of 1968, the miiothers in the saniple had completed a utilization questionnaire.
At that time, the experimental families had
received comprehensive care on the average for three years, while the total population had the benefits of Medicaid available for a shorter time.
The titilization questionnaire covered the year
from the late winter of 1967 to the late winter of 1968, so the qtiestionnaire covered the second year after Medicaid’s initiation.
In the experimental group, the per-child ratio
of contacts with all medical facilities remained
essentially tmchanged from 1964 to 1968, (6.12 and 6. 10), btit in the control group there was a
decrease (from 6.59 to 5.94). Such a decrease might be surprising to those who expected that the introduction of Medicaid would increase the patient-physician contacts of the low-income population. In the present sample, however, the median age of children increased between 1964 and 1968, and, since older children go to physi-cians less often, this may explain partially the
lower per-child ratio of contacts in 1968. The
sustained ntimber of visits in the experimental group probably restilted from the more frequent health supervision of these children.
Following the introduction of Medicaid, the
utilization of private physicians in the control families increased more than three-fold from 0.58 visits per child in 1964 to 1.90 visits per child in 1968. The social changes taking place during the experiment-the introduction of Medicaid and generally rising incomes-put the use of private physicians within the reach of many low-income
famiiilies. The experiniental group, which had the primiiary care program, also increased its use of private physicians in somiie degree (0.59 per child
in 1964 to 0.78 per child in 1968) but clearly not
to the degree in the control families. An analysis of the utilization of private physicians showed that in the control families the imicreased use of
private physicians occurred almost exclusively in
white families and mio such increase was noted in black families. Apparently the primary care
physicians were able to gain the trust of the black patients, while this situation did not exist for the control families. In the ctirrent atmosphere of
continued strained race relations in the inner city,
this was no small accomplishment.
No one reached out to the blacks in the control group and their old pattern of acqtiiring medical
care continued. Black families in the control group had similar patterns of muedical care usage before and after the Medicaid legislation. The relative lack of infitmence of Medicaid on the
pattern of medical care amomig blacks in the
control grotip was discotiraging. In spite of their
initial dislike of stich clinics and the newly
provided means to pay for private care, they
contintied to tise the established fragmiiemited
system. These findings suggest that to provide a
medical care payment miiechanismii is not enough
to extricate black famiiilies froni the old system. Continued mistrust of inipersonal miiedicine nitist be dealt with by providing the kinds of services, like the independent variable in this experiment, that the best of neighborhood health centers can provide.
One of the original criteria for inclusion in the
present sttidy included residence within three miiiles of the clinic and the intention to remnain
there for three years. In spite of these criteria and
the continued involvement of a few families who moved outside this boundary, 15% of those origi-nally engaged in the study or program moved far enough away that they cotild no longer be
included.
In addition, 66% of the famiiihies who remained
active throtighotit the sttidy miioved at least once
during the three years. The three-miiile radius included about one half of the city of Boston and
large sections of the adjacent towns of Brookline
and Cambridge. We could not estimate the
degree to which a neighborhood health center
would have lost or had to transfer patients
because of the large number of residential moves.
Only two such facilities operated within the three-mile radius during the study, affecting only
HEALTH CARE DELIVERY
TABLE X
AVERAGE NUMBER OF MEDICAL CONTACTS PER CHmLD IN THIRD YEAR OF STUDY BY AGE AND FACILITY
Experiinen t#{252}lGroup Contra 1 Group
Oto4 5to9 lOtol4 15+
Oto4 5to9 IOtol4 15+
Facility yr yr yr yr yr yr yr yr
Experimnental clinic 3.37 2.44 1.81 1.17 - - -
-Other hospital clinics 0.39 1.44 2.61 1.49 2.44 2.22 2.89 2.27
Total hospital clinics 3.76 3.88 4.42 2.66 2.44 2.22 2.89 2.27
Private physicians 0.56 0.53 0.59 1.50 1.20 1.21 1.78 1.59
Other facilities 0.61 0.63 1.00 0.99 2.54 1.62 1.58 0.96
Total 4.93 5.04 6.01 5.15 6.18 5.05 6.25 4.82
Numberof childremi 118 232 161 94 133 280 170 98
that a given facility with inflexible boundaries is not able to provide comprehemisive care for a
significant segment of the low-income poptilation
for an extended length of timiie becatis#{235} the population is so mobile. Forttmnately, in 1975,
strict residemicy boundaries are not enforced and
the neighborhood health system is delivering miiore and more of the personal health services
needed by inner-city families.
THE PROBLEM OF DISENGAGEMENT
Some of the observed disengagement towards
the end of the study as miieastired by simuilar “no-show” rates, similar hospitalization rates, amid
siniilar illness visits rates between the
experi-muemitab and control groups can be credited to
failures of the primiiary care program. Most,
however, cami be explained by the welfare status
of the faniily and the increasing age of the
childremi in the faniily.
The relatiomiship between tise of the priniary
care program and age of the children is clear.
Table X presemits the average number of visits per
child to the comprehensive care clinic, other hospital climiics, private physicians, and other facilities categorized by age. In the experimiiental group, use of the primary care climiic decreased with age of the child and there was a
corre-sponding increase imi the tise of other hospital
clinics tip to the niid-teens. Youmig people iii the tipper teemis iiiore often vent to private physi-cians. There may have been some resistance among these youngsters to being identified as a child by contimitiing to attend a “children’s” clinic. In addition, the older child might see his physiciami only omice each year for health supervi-sioii. The turmiover of physicians nieant that this child, unlike the infant, cotild see a different
physician each time for health supervision. For the older child, especially, continuity was not
delivered.
The major factor, however, which was related
to disengagemiient froni the primary care program
was whether or not the family was on welfare.
The dimiiinished differences between the
experi-niental and control groups occurred primarily in
welfare families. Table X presents the
hospitahiza-tion rate per 100 children for each of the six-nionthi periods of the study categorized by whether or not the famiiily received welfare. The expermniental families omi welfare showed a
decreased hospitalization rate over the first 18
months of the study amid an increased rate (at
somime points higher than the control grotip) over the latter 18 months. Imi contrast, the nonwelfare
famiiihies in the experimiientab group had a
consist-emitly lower hospitalization rate than their
cotin-terparts in the control group after the initial six
months.
The difference in site of the hospitalization in the final year showed that the welfare families in the experimental group were niuch more often hospitalized in hospitals other than the back-tip facility which the primary care climuic physicians
tised. Only 5 of 12 hospitalizations of children on
welfare were at the back-tip hospital compared to 15 of 18 hospitalizations in the nonwelfare exper-imiiental families. Thus, the physicians in the primary care program had no control over the majority of the hospitalizations of welfare patients in the final year of the study.
The data on surgical procedtires showed the
sanie trends as hospitalizations. As one cami see in
Table XII, operations were lower in the
experi-miiemital group than in the comitrol group for
nonwelfare famimilies froni the latter part of the
TABLE XIII
MONTHLY ILLNESS VISITS PER 100 CHILDREN AT APPROXmMATE SIX-MONTH INTERVALS CATEGORIZED BY
WELFARE AND EXPERIMENTAL STATUS
TABLE XI TABLE XII
HOSPITALIZATION RATE PER 100 CHILDREN DURING Six-MONTH PERIODS CATEGORIZED BY WELFARE AND
EXPERIMENTAL STUDIES
Welfare Nonwelfare
Families Families
Time Erperi-
Experi-Period mental Control mental Control
(mo) Group Group Group Group
0 to 6 6.0 3.5 3.6 1.8
7 to 12 3.6 6.7 2.8 3.2
13 to 18 2.7 5.0 1.5 2.9
19 to 24 3.1 2.5 1.5 4.0
25 to 30 3.6 4.7 3.0 3.8
31 to 36 5.6 4.6 2.3 3.2
OPERATION RATE DURING SIx-Mors-rH PERIODS
CATEGORIZED BY WELFARE AND EXPERIMENTAL STATUS
Welfare Nonwelfare
Families Families
-Time Experi-
Erperi-Period mental Control mental Control
(mo) Group Group Group Group
0 to 6 0.9 0.3 2.6 0.8
7 to 12 0.6 1.0 1.3 2.7
13 to 18 0.9 0.2 0.8 2.6
19 to 24 0.8 0.2 1.2 4.9
25 to 30 0.8 0.7 2.1 3.7
31 to 36 2.1 0.5 1.6 4.4
operations in the experimental group toward the end of the study occurred in the welfare
fami-lies.
While in the experimental group surgery occurred more frequently in the welfare families
than in the nonwelfare families, the opposite is
true in the control group where surgery was generally less frequent in the welfare families. We do not know the degree to which this reflects unmet need. There was no difference in elective stirgery between welfare and nonwelfare fami-lies.
A final table in this group illustrates the consist-ency of these findings (Table XIII). Illness visits per 100 children shown decreased in the experi-mental group during the first 18 months and returned to the preexpenimental level by the final
six months of the three years among the welfare
families. The nonwelfare families in the
experi-mental group had decreased illness visits during
the first 18 months, slight increases for one year,
and then a decrease to the lowest level in the final
six months, considerably below their counterparts in the control group.
There is, in fact, no statistical explanation for
the reasons for the disengagement of welfare recipients since this finding was discovered after the experiment was terminated. Before the Medi-care-Medicaid legislation of 1966, welfare fami-lies usually were required by welfare to use the Municipal Hospital. Considerable negotiation with the Department of Public Welfare was required to gain consent for the families to be treated in the experimental clinic and hospital-ized elsewhere when needed. Welfare officials were miiost cooperative.
Welfare workers, however, are overloaded
Welfare
Families
Nonwelfare
Families
Time Period
(mo)
, ‘
Experi-mental Control
Group Group
Experi-mental Control
Group Group
Preexperi-mental
23.9 24.1 22.7 21.2
6 20.1 19.5 15.5 19.2
12 12.5 26.5 15.4 28.4
18 19.3 22.5 15.1 21.4
24 20.1 11.6 17.2 23.1
30 21.4 18.0 18.6 119.4
36 24.6 26.9 13.1 20.1
with work and sometimes resistant to change. To have to make an exception for a few families probably was not welcomed by some. The social workers in the primary care program reported that some families were told by public welfare workers to go to other hospitals even after the notification that they cotild use the new program.
Long after the Medicare-Medicaid legislation,
which allowed welfare families to use whatever facilities they wished, some welfare workers still had not conveyed this information to their clients.
Since the families in our samiiple used niany
facilities, these admonitions were not always
HEALTH CARE DELIVERY
high amid this may hav#{231}added to the comifimsiomi of where famiiibies could go for care.
It is posSil)le, of course, that those families who
were told that they were free to go anywhere they wished, chose to exercise this newly found freedom to the fullest, amid represented a rejectiomi of the primary care program.
SUMMARY
By offerimig primary care to a small grotip of
low-incoiiie families iii the city of Boston, a
planned innovation was imitrodticed into their health care. The program was designed to be an
experimiient imi two important problemiis of
contemporary American niedicine-primary care
as a mode of delivering health service and syste-matic care givemi to the poor imi the inner city.
These findings indicate that the effects of primary care are appreciable. The provisiomi of such care decreases hospitalizations, surgical procedtires, and illmiess visits to the physician; increases health supervision visits; increases patient satisfactiomi; and reduces the use of the laboratory amid accompanying charges. There was
Iio evidemice that patient miiorbidity was altered.
However, these general restilts were miiodified by
differemitial effects omi subpopulations such as
families omi welfare.
Some of these fimidings are similar to other studies; some are different. Clearly there is a lack
of imiformatiomi omi the outcomes, i.e., miieasured
bemiefits of primary care programs. Descriptive
inforniation is needed but so are methodologically soumid experimiiemits2 with proper control groups,
especially in settings which provide continuity
such as the mieighborhood health center and
private practice. As new educational programs in primiiary care develop, it becomes even more iniportant to have comitrohled comparisons between different models. Clearly these issues have mliajor
mi
plications for pediatric trainingprogranis. Whatever solutions develop for the
delivery of primarY care for children, it is hoped that these solutiomis will be based on the best
available data amid will be the responsibility of
professionals who have a demonstrated
imivest-mTnent amid comitintied concern for health needs of
children.
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