Public & Community Health

Primary care and public health both have crucial roles to play in improving and maintaining community health. Their integration and cooperation are important but not always achieved. Primary care has the challenge of moving beyond its traditional role of treating only the patients who appear at its doorstep to move to define and engage the community around it. Public health must seamlessly communicate population needs and threats to clinicians and patients and help to coordinate the location and delivery of care. The Graham Center supports the integration of public health and primary care by providing tools that can be used by both sectors.

COPC Curriculum

We developed a curriculum for community-oriented primary care that can be used to train doctors and other staff how to incorporate community needs into practice activities.

View the COPC Curriculum »

Maps and Workforce Projections

The Graham Center's mapping programs and workforce projections can help public health agencies plan and implement health and healthcare improvement projects at local, state, and national levels.

View Maps, Data, and Tools »

Narrow Results:

  • What Do We Need to Know About the Presidential Candidates’ Health?

    Commentaries & Editorials | Oct 06, 2016 | Douglas Kamerow, MD

    History supplies some cautionary tales of public lack of knowledge about presidential health.

  • Rural Opioid Use Disorder Treatment Depends on Family Physicians

    One Pagers | Oct 03, 2016 | Peter Wingrove, BS; Brian Park, MD, MpH; and Andrew Bazemore, MD, MpH

    The nation’s growing opioid use disorder epidemic disproportionately impacts rural areas.

  • Family Medicine: An Underutilized Resource in Addressing the Opioid Epidemic?

    One Pagers | Aug 22, 2016 | Jacob Crothers, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Peter Wingrove, BS

    Despite a clear willingness to prescribe opioids, few family physicians (FPs) have the necessary certification to treat opioid use disorder with buprenorphine, an effective, evidence-based treatment.

  • How to React to the Orlando Massacre?

    Commentaries & Editorials | Jun 14, 2016 | Douglas Kamerow, MD

    Harm reduction may have something to offer

  • Finally the US Regulates e-Cigarettes as Tobacco

    Commentaries & Editorials | May 06, 2016 | Douglas Kamerow, MD

    The FDA has finally issued 500 pages of regulations for e-cigarettes, cigars, pipe tobacco, and hookahs.

  • HPV Vaccine: Effective but Underused in the U.S.

    Commentaries & Editorials | Apr 14, 2016 | Douglas Kamerow, MD

    Vaccines to prevent HPV were licensed in the United States and recommended for all adolescent girls in 2006. Recommendations to vaccinate boys started in 2011. The good news, recently confirmed in a US study of females aged 14-34, is that HPV vaccine can prevent HPV infection; the bad news is that we’re not doing a good job of getting the vaccine into our children.

  • Perspectives in Primary Care: A Conceptual Framework and Path for Integrating Social Determinants of Health Into Primary Care Practice

    Articles | Mar 09, 2016 | Jennifer DeVoe, MD, DPhil; Andrew Bazemore, MD, MPH; Erika Cottrell, PhD, MPP; Sonja Likumahuwa-Ackman, MID, MPH; Jene Grandmont, MA; Natalie Spach; and Rachel Gold, PhD, MPH

    The United States falls behind other industrialized nations on most health indicators and remains plagued by stark health disparities. Efforts to understand the factors underlying these persistent inequalities and other shortcomings highlight the role of social determinants of health (SDH).

  • Bottled Water for All, All the Time?

    Commentaries & Editorials | Mar 01, 2016 | Douglas Kamerow, MD

  • A Modest Proposal on Gun Control—and a Real One

    Commentaries & Editorials | Jan 08, 2016 | Douglas Kamerow, MD

    A smart legislator in the state of Missouri has come up with a good idea to protect the US from gun violence.

  • Fewer Americans Report a Personal Physician as Their Usual Source of Health Care

    One Pagers | Dec 15, 2015 | Anuradha Jetty, MPH; Larry Green, MD; Andrew Bazemore, MD, MPH; Stephen Petterson, PhD

    One in five Americans reports no usual source of health care, and the number of Americans reporting that they have a personal relationship with a usual source of care has declined steadily over the past 15 years.

  • 2015 PCORI Report38 page PDF

    Reports | Dec 01, 2015 | The Robert Graham Center

  • An Unexpected Headline: More US White People are Dying

    Commentaries & Editorials | Nov 24, 2015 | Douglas Kamerow, MD

    Contrary to decreasing overall mortality rates, mortality rates for middle-aged whites are actually going up, according to a recent article in the Proceedings of the National Academy of Sciences.

  • Fuming About E-Cigarettes and Harm

    Commentaries & Editorials | Aug 26, 2015 | Douglas Kamerow, MD

    Among the criticisms that public health officials have leveled at electronic cigarettes are that they are dangerous to health and that their flavors and easy availability are enticing and recruiting new smokers, especially young people. A new report from Public Health England, however, takes a surprisingly different view.

  • “Community Vital Signs”: Incorporating Geocoded Social Determinants into Electronic Records to Promote Patient and Population Health

    Articles | Aug 01, 2015 | Andrew Bazemore, MD, MPH; Erika Cottrell, PhD; Rachel Gold, PhD; Lauren Hughes, MD, MPH; Robert Phillips, MD, MSPH; Heather Angier, MA; Timothy Burdick, MD; Mark Carrozza, MA; and Jennifer DeVoe, MD, DPhil

    Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes.

  • Why Don't People Exercise, Even a Little?

    Commentaries & Editorials | Jun 04, 2015 | Douglas Kamerow, MD

    The US Centers for Disease Control and Prevention says that 26.3% of US adults engaged in no leisure-time activity in 2013.

  • Teaching Population Health in the Digital Age: Community-Oriented Primary Care 2.0

    Articles | May 18, 2015 | Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; and Jennifer Rankin, PhD

    Providers and educators lack the tools and models necessary to address community problems. We describe an online curriculum intended to teach learners how to adapt established Community-Oriented Primary Care (COPC) principles for an age of ready access to clinical and population data and geospatial technology.

  • More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalization

    Articles | May 01, 2015 | Andrew Bazemore, MD; Robert Phillips, MD, MSPH; Petterson, Stephen, PhD; and Lars Peterson, MD, PhD

    Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.

  • Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035

    Articles | Mar 16, 2015 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Carol Tran, MD; and Andrew W. Bazemore, MD MPH

    The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes.

  • Only One Third of Family Physicians Can Estimate Their Patient Panel Size

    Articles | Mar 16, 2015 | Lars Peterson, MD, PhD; Anneli Cochrane, MPH; Andrew Bazemore, MD, MPH; Elizabeth Baxley, MD; and Robert Phillips, MD, MSPH

    In addition to payments for services rendered to individual patients, primary care physicians will increasingly be paid for their ability to achieve goals across the body of patients most closely associated with them: their “panel.” In a 2013 survey, however, only one third of family physicians could estimate their panel size, raising concern about their ability to perform more advanced primary care functions.

  • Maintenance of Certification, Medicare Quality Reporting, and Qualification of Diabetes Care

    Articles | Mar 02, 2015 | Robert Phillips, MD, MSPH; Brenna Blackburn, MPH; Lars Peterson, MD, PhD; and James Puffer, MD

    Aligning maintenance of certification with quality reporting may ease reporting burden, but the impact on quality is uncertain. This study compared changes in quality measures from American Board of Family Medicine Performance in Practice Modules (PPMs), Physician Quality Reporting System (PQRS), and a combined PQRS/PPM for diabetes between 2008 and 2012.

  • Calling All Scholars to Council of Academic Family Medicine Educational Research Alliance (CERA)

    Articles | Mar 02, 2015 | Shokar Navkiran, MD, MPH; GeorgeBergu, MD; Andrew Bazemore, MD, MPH; Randall Clinch, DO, MS; Andrew Coco, MD, MS; Betsy Jones, EdD; Arch Mainous III, PD; Dean Seehusen, MD, MPH; and Vijay Singh, MD, MPH

    The current state of affairs is that as a specialty, we underperform in scholarly and research output compared with our peers in other specialties, and although this has been acknowledged for a while, improvements in research productivity have been slow. Many barriers remain to the generation of research and scholarly output from departments of family medicine.

  • Public Health and Community Medicine Instruction and Physician Practice Location

    Articles | Nov 01, 2014 | Imam Xierali, PhD; Rika Maeshiro, MD, MPH; Sherese Johnson, MPH; Taniececea Arceneaux, PhD; and Malika Fair, MD, MPH

    Background: Experts have historically recommended better integration of public health content into medical education. Whether this adoption is associated with physician practice location has not been studied.

  • Health is Primary: Family Medicine for America's Health

    Articles | Oct 01, 2014 | Perry A. Pugno, MD, MPH; John W. Saultz, MD; Michael L. Tuggy, MD; Jeffrey M. Borkan, MD, PhD; Grant S. Hoekzema, MD; Jennifer E. DeVoe, MD, DPhil; Jane A. Weida, MD; Lars E. Peterson, MD, PhD; Lauren S. Hughes, MD, MPH; Jerry E. Kruse, MD, MSPH; James C. Puffer, MD

    More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to “renew the specialty to meet the needs of people and society,” this article reviews the important results of this collaboration.

  • Impact of Global Health Experience During Residency in Graduate Practice Location: A Multiple Cohort Study

    Articles | Sep 01, 2014 | Winston Liaw, MD; Andrew Bazemore, MD, MPH; Imam Xierali, PhD; John Walden, MD; and Phillip Diller, MD, PhD

    The impact of global health experiences on practice location is not clear. Graduates of programs with global health experiences were more likely to practice in an underserved or rural area. Making these experiences available may affect participants and nonparticipants.

  • Factors Influencing Family Physicians' Contribution to the Child Health Care Workforce

    Articles | Sep 01, 2014 | Laura Makaroff, DO; Xierali Imam, PhD; Stephen Petterson, PhD; Scott Shipman, MD, MPH; Andrew Bazemore, MD, MPH; and James Puffer, MD

    We wanted to explore demographic and geographic factors associated with family physicians' provision of care to children. We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of FamilyMedicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children.

  • Winnable Battles: Family Physicians Play an Essential Role in Addressing Tobacco Use and Obesity

    One Pagers | Jun 05, 2014 | Joseph Nichols MD, MPH and Andrew Bazemore, MD, MPH

    Tobacco use and obesity are linked to most deaths and significant disability in the United States, and family physicians are uniquely positioned to address these issues. This highlights a need for transforming primary care practices and teams to systematize the recognition and management of unhealthy behaviors, and for alternative payment models that support these efforts.

  • Making the Case: Family Medicine for America's Health53 page PDF

    Presentations | Apr 15, 2014 | Andrew Bazemore, MD, MPH

    Making the Case: Family Medicine for America’s Health

  • Family Physician Participation in Quality Improvement

    Articles | Nov 01, 2013 | Lars Peterson, MD, PhD; Carlos Jaen, MD, PhD; and Robert Phillips, MD, MSPH

    More than one-third of family physicians reported participating in a quality improvement (QI) activity in the past year. Continuous QI is vital to improving personal and population health outcomes and reducing costs. Support for QI activities, their evaluation, and the dissemination of successful efforts are sorely needed.

  • Training a Health Care Workforce to Meet Your State's Needs (and Wants)35 page PDF

    Presentations | Apr 15, 2013 | Andrew Bazemore, MD, MpH

    Training a Health Care Workforce to Meet Your State's Needs (and Wants): Addressing Challenges: Data, Tools and Primary Care

  • Health Care Transition

    One Pagers | Dec 01, 2012 | Patricia A. Stoeck, Md; Newton Cheng, Ms; Anne J. Berry, Ba; Andrew W. Bazemore, Md, Mph; And Robert L. Phillips, Jr., Md, Msph

    Youth with special health care needs who receive care within a patient-centered medical home (PCMH) are significantly more likely to receive services for transitioning to adult care. Broader implementation of the PCMH may contribute to wider use of health care transition counseling and enhanced support for such patients as they prepare to enter adulthood.

  • Is Exposure to Student-Run Clinic Associated with Future Primary Care Practice?

    Articles | Sep 15, 2012 | Sebastian Tong, MD, MPH; Robert Phillilps, MD,MSPH; and Rebecca Berman, MD

    This study explored whether or not there is an association between presence of a student-run clinic at a medical school and future practice of medical school graduates in a primary care specialty through using a 2005 survey of all student-run clinics associated with medical schools, supplemented by direct survey of schools missing from this dataset. No association between having a student-run clinic in 2005 at a medical school and proportion of its graduates who currently practice primary care was found.

  • A Re-emerging Political Space for Linking Person and Community Through Primary Health Care

    Articles | Jun 15, 2012 | Sarah A. Sweeney, BS; Andrew Bazemore, MD, MPH; Robert L. Phillips Jr, MD, MSPH; Rebecca S. Etz, PhD; and Kurt C. Stange, MD, PhD

    Objectives: We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities. Methods: We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard–defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion–crystallization analysis approach to identify themes. Results: We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas. Conclusions: Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

  • Communities of Solution: The Folsom Report Revisited

    Articles | May 15, 2012 | Sarah Lesko, MD, MPH; Kim S. Griswold, MD, MPH; Sean P. David, MD, SM, DPhil; Andrew W. Bazemore, MD, MPH; Marguerite Duane, MD, MHA; Thomas Morgan, MD; John M. Westfall, MD, MPH; C. Everett Koop, MD, SciD; Betsy Garrett, MD; James C. Puffer, MD; and Larry A. Green, MD

    Efforts to address the current fragmented US health care structure, including controversial federal reform, cannot succeed without a reinvigoration of community-centered health systems. A blueprint for systematic implementation of community services exists in the 1967 Folsom Report—calling for “communities of solution.” We propose an updated vision of the Folsom Report for integrated and effective services, incorporating the principles of community-oriented primary care. The 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes. Current policy reform efforts should build upon Folsom Report’s goal of transforming personal and population health.

  • Where the United States Falls Down and How We Might Stand Up

    Commentaries & Editorials | Nov 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    The Commonwealth Fund and Rand Europe announced this week that the United States ranks last among developed countries in “mortality amenable to health care” — that is, deaths that are considered preventable with timely and effective health care. Preventable death rates declined during the last decade, but the rate of improvement in the United States was slower compared with other countries such that we continue to fall further behind. Compared with other countries, the United States also has much wider disparities in health status and outcomes.

  • Using Maps to Strengthen Your Case: A Robert Graham Center Deep Dive19 page PDF

    Presentations | Jul 17, 2011 | Sean Finnegan, MS; Sarah Lesesne, MSPH; Mark Carrozza, MA; Michael Topmiller, MS et al

  • I LIVE PC: International Learning on Increasing the Value and Effectiveness of Primary Care253 page PDF

    Monographs & Books | Apr 15, 2011 | Robert Graham Center

    View the conference packet from the 2011 International Learning on Increasing the Value and Effectiveness of Primary Care (I LIVE PC) conference, held April 4-5 in Washington, D.C.

  • Online Mapping and GIS22 page PDF

    Presentations | Apr 11, 2011 | Sean Finnegan, MS

    Online Mapping and GIS: Advances in Technology and Challenges of Putting the Power of GIS into the Hands of Non-Geographers

  • You're Expecting Me to Become a GIS Expert?22 page PDF

    Presentations | Apr 11, 2011 | Jennifer Rankin MS, MPH, PhD

    You're Expecting Me to Become a GIS Expert? Teaching GIS to Users of Online Mapping Tools

  • Avertable Deaths Associated with Household Income in Virginia

    Articles | Feb 15, 2010 | SH Woolf, MD, MPH; RM Jones, PhD, MPH; RE Johnson, PhD; RL Phillips Jr, MD, MSPH; MN Oliver, MD; AW Bazemore, MD, MPH; A Vichare, MPH

    Objectives: We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. Methods: Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. Results: If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range=21.8%–28.1%) would not have occurred. An annual mean of 12954 deaths would have been averted (range=10548–14569), totaling 220211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. Conclusions: Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary—that health suffers when society is exposed to economic stresses—is especially timely amid the current recession. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes.

  • The Impact of a Clinic Move on Vulnerable Patients with Chronic Disease: A Geographic Information Systems (GIS) Analysis

    Articles | Jan 15, 2010 | Andrew Bazemore, MD, MPH, Philip Diller, MD, PhD, and Mark Carrozza, MA

    Background: Changing locations disrupts the populations served by primary health care clinics, and such changes may differentially affect access to care for vulnerable populations. Methods: Online geographic information systems mapping tools were used to define how the relocation of a family medicine center impacted access to care for black and Hispanic patients with chronic disease. Results: Maps created from practice management data revealed a distinct shift in black and Hispanic patients with chronic disease being served in the new location. Conclusions: Geographic information systems tools are valuable aids in defining changing service areas of primary health care clinics.

  • Family Medicine, the NIH, and the Medical-Research Roadmap: Perspectives from Inside the NIH

    Articles | Mar 15, 2009 | Sean C. Lucan, MD, MPH; Frances K. Barg, PhD, MEd; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr, MD, MSPH

    PURPOSE: Family medicine has had little engagement with the National Institutes of Health (NIH), and it is unclear what NIH officials think about this. METHODS: Purposive sampling identified 13 key informants at NIH for open-ended, semi-structured interviews. Evaluation was by content analysis. RESULTS: NIH officials expressed the perception that family physicians have strong relationships with patients and communities and focus on interdisciplinary collaboration but that they do limited research and have weak research infrastructure. They also indicated that NIH has repackaged its stated focus, to include areas of research that might be applicable to family medicine, but whether this represents real change is questionable; NIH still emphasizes basic science and exclusionary trials. While NIH officials suggested that family physicians still have no obvious NIH home, they also suggest that family physicians are well-poised to recruit patients and inform questions, if not lead research. Family physicians have opportunity with Clinical and Translational Science Awards (CTSAs) but need areas of expertise and additional formal research training to succeed with greater research participation. CONCLUSIONS: NIH key informants generally appreciated family medicine clinically but viewed family medicine research as underdeveloped. Some identified opportunities for family medicine to lead, particularly CTSAs. Greater self-advocacy, research training, and developing areas of expertise may improve family medicine’s engagement with NIH.

  • Common Measures, Better Outcomes: A Field Test of Brief Health Behavior Measures in Primary Care

    Articles | Nov 01, 2008 | Douglas Fernald , MA; Desiree Froshaug, MS; Miriam Dickinson, PhD; Bijal Balasubramanian, MBBS, PhD; Martey Dodoo, PhD; Jodi Summers Holtrop, PhD; CHES, Dorothy Hung, PhD, MA, MPH; Russell Glasgow, PhD; Linda Niebauer; and Larry Green, MD

    Primary care offices have been characterized as underutilized settings for routinely addressing health behaviors that contribute to premature death and unnecessary suffering. Practical tools are needed to routinely assess multiple health risk behaviors among diverse primary care patients. The performance of a brief set of behavioral measures used in primary care practice is reported here.

  • Access Transformed: Building a Primary Care Workforce in the 21st Century40 page PDF

    Monographs & Books | Aug 15, 2008 | Robert Graham Center

    Access transformed: Building a primary care workforce for the 21st century

  • Testing Process Errors and Their Harms and Consequences Reported from Family Medicine Practices: A sSudy of the American Academy of Family Physicians National Research Network

    Articles | Jun 15, 2008 | Hickner J, Graham DG, Elder NC, Brandt E, Emsermann CB, Dovey S, Phillips R

    CONTEXT: Little is known about the types and outcomes of testing process errors that occur in primary care. OBJECTIVE: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff. DESIGN: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting. SETTING AND PARTICIPANTS: 243 clinicians and office staff of eight family medicine offices. MAIN OUTCOME MEASURES: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors. RESULTS: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p<0.05) existed between error types and type of reporter (clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients' race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45-64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm. CONCLUSIONS: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

  • HealthLandscape 101: Putting Family Medicine on the Map5 MB PDF

    Presentations | May 15, 2008 | Robert Phillips, MD, MSHP

  • Integrating Primary Care and Mental Health/Substance Use22 page PDF

    Presentations | Mar 15, 2008 | Bob Phillips, MD, MSPH, and Mary Jane England, MD

  • The Patient Centered Medical Home: History, seven core features, evidence and transformational change32 page PDF

    Monographs & Books | Nov 15, 2007 | Robert Graham Center

    The Patient Centered Medical Home: History, seven core features, evidence and transformational change

  • The Shoulder to Shoulder Model: Channeling medical volunteerism toward sustainable health change

    Articles | Oct 15, 2007 | Heck JE, Bazemore A, Diller P

    BACKGROUND: Rapid growth in medical volunteerism in resource-poor countries presents an opportunity for improving global health. The challenge is to ensure that the good intentions of volunteers are channeled effectively into endeavors that generate locally acceptable, sustainable changes in health. METHODS: Started in Honduras in 1990, Shoulder to Shoulder is a network of partnerships between family medicine training programs and communities in Honduras and other resource-poor countries. The program involves short-term volunteering by US health professionals collaborating with community health boards in the host countries. The program has been implemented in seven US family medicine training programs and is supported by a small international staff. RESULTS: During the 16 years of program operation, more than 1,400 volunteers have made visits to host countries, which include Honduras, Ecuador, and Tanzania. Clinics have been established, school-based food programs and community-based water filtration programs developed, and cancer screening and pregnancy-care programs put in place. These and other programs have been implemented on a budget of less than $400,000, raised through donations and small grants. CONCLUSIONS: The Shoulder to Shoulder model allows health care professionals to channel short-term medical volunteerism into sustainable health partnerships with resource-poor communities. The resulting network of partnerships offers a powerful resource available to governments and foundations, poised to provide innovative interventions and cost-effective services directly to poor communities.

  • Going Global: Considerations for Introducing Global Health into Family Medicine Training Programs

    Articles | Oct 15, 2007 | Evert J, Bazemore AW, Hixon A, Withy K

    Medical students and residents have shown increasing interest in international health experiences. Before attempting to establish a global health training program in a family medicine residency, program faculty must consider the goals of the international program, whether there are champions to support the program, the resources available, and the specific type of program that best fits with the residency. The program itself should include didactics, peer education, experiential learning in international and domestic settings, and methods for preparing learners and evaluating program outcomes. Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.

  • Access Denied: A Look at America's Medically Disenfranchised42 page PDF

    Monographs & Books | Aug 01, 2007 | The Robert Graham Center, National Association of Community Health Centers

  • An Acess Deprivation Index & HealthLandscape14 page PDF

    Presentations | Apr 15, 2007 | Robert Phillips, MD, MSPH, and Andrew Bazemore, MD, MPH

    An access deprivation index and HealthLandscape

  • Primary Care Physicians’ Perceptions of the Effect of Insurance Status on Clinical Decision Making

    Articles | Mar 01, 2006 | David Meyers, MD; Ranit Mishori, MD; Jessica McCann, MA; Jose Delgado, MD; Ann O'Malley, MD; and Ed Fryer, PhD

    Americans who do not have health insurance receive fewer health services and have poorer health status than those who have insurance. To better understand this disparity, in this study we characterize primary care physician’s perceptions of what effect, if any, patients’ insurance status has on their clinical decision making during office visits.

  • UK Lessons for US Primary Care

    Commentaries & Editorials | Nov 15, 2005 | Marey Dodoo, Martin Roland, and Larry A. Green

    Primary care is now acknowledged to be a foundation of effective, sustainable health care for populations, with favorable effects on access to care, comprehensiveness, continuity, efficiency, and equity. In addition, variation in health care arrangements and policies across nations presents opportunities to compare and learn across national boundaries about what is working and how well in primary care. It would be advantageous for key U.S. organizations devoted to optimizing primary care to sustain for the foreseeable future exchanges with other countries to enable the United States to see itself more clearly, import innovations of relevance, and elude avoidable mistakes. While there is much to learn in many countries, U.K.-U.S. exchanges present immediate opportunities with particularly great relevance. It is not as if there is little to learn from one another. Rather, it is how much can be learned that can find prompt application in the redesign of primary care that is underway.

  • Using the Ecology Model to Describe the Impact of Asthma on Patterns of Health Care

    Articles | May 15, 2005 | Barbara P. Yawn, George E. Fryer, Robert L. Phillips, Jr., Susan M. Dovey, David Lanier, Larry A. Green

    BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.

  • Adding More Specialists is Not Likely to Improve Population Health: Is Anybody Listening?

    Commentaries & Editorials | Mar 24, 2005 | Robert L. Phillips Jr., MD, MSPH; Martey S. Dodoo, and Larry A. Green, MD

    Before a shortage of physicians, and particularly subspecialists, in the United States is declared, it is worth reviewing the considerable evidence that calls into question whether further specialization automatically improves health. should lead to purposeful choices about what we want them to do and the outcomes we expect.

  • Variation in Participation in Health Care Settings Associated with Race and Ethnicity

    Articles | Oct 15, 2004 | Erika B. Bliss, MD; David S. Meyers, MD; Robert L. Phillips, Jr., MD, MSPH; George E. Fryer, PhD; Susan M. Dovey, MPH, PhD; and Larry A. Green, MD

    OBJECTIVE: To use the ecology model of health care to contrast participation of Black, Non-Hispanics (Blacks), White, Non-Hispanics (Whites), and Hispanics of any race (Hispanics) in five health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of Black, White, and Hispanic people per thousand receiving health care in each setting. SETTING: physicians’ offices, outpatient clinics, hospital emergency departments, hospitals, and people’s homes. MAIN OUTCOME MEASURE: Number of people per 1000 per month who had at least one contact in a health care setting. RESULTS: Fewer Blacks and Hispanics than Whites received care in physicians’ offices (154 vs 155 vs 244 per 1000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than Blacks or Whites received home health care services (7 vs 14 vs 14 per 1000 per month, respectively). After controlling for 7 variables, Blacks and Hispanics were less likely than Whites to receive care in physicians’ offices [Odds Ratio (OR) = 0.65, 95% Confidence Interval (CI) = 0.60-0.69 for Blacks and OR = 0.79, 95% CI = 0.73-0.85 for Hispanics], outpatient clinics (OR = 0.73, 95% CI = 0.60-0.90 for Blacks and OR = .71, 95% CI = 0.58-0.88 for Hispanics), and hospital emergency departments (OR = 0.80, 95% CI = 0.69-0.94 for Blacks and OR = 0.80, 95% CI = 0.68-0.93 for Hispanics) in a typical month. There was no significant difference between the groups in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: Fewer blacks and Hispanics than whites received healthcare in physicians’ offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.

  • Geographic Retrofitting: A Method of Community Definition in Community-Oriented Primary Care Practices

    Articles | Jun 15, 2004 | Fitzhugh Mullan, MD; Robert L. Phillips, Jr, MD, MSPH; Edward L. Kinman, PhD

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  • Splitting the Difference: Patient Preference vs Conservation of Resources

    Commentaries & Editorials | Jun 15, 2004 | Robert Phillips, Jr., MD, MSPH

    Splitting the difference: Patient preference vs conservation of resources

  • Oral Vitamin D3 Decreases Fracture Risk in the Elderly

    Articles | Jun 16, 2003 | Janelle Guirguis-Blake, MD, and Robert L. Phillips, Jr., MD, MSPH

    Vitamin D3 (or its physiologic equivalent, ergocalciferol), administered at a dose of 100,000 IU every 4 months for 5 years, is effective for primary prevention of fractures in the active elderly aged 65 to 85 years. This treatment regimen has no effect on cardiovascular, cancer, or all-cause mortality. Despite a seemingly large dose averaging 800 IU per day, this regimen is a safe, cheap (<$2 per year), and effective therapy for primary prevention of fractures.

  • Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care

    Articles | May 15, 2003 | DeVoe JE, Fryer GE, Phillips R, Green L

    OBJECTIVES: This study ascertained the separate and combined effects of having insurance and a usual source of care on receiving preventive services. METHODS: Descriptive and multivariate analyses of 1996 Medical Expenditure Panel Survey data were conducted. RESULTS: Receipt of preventive services was strongly associated with insurance and a usual source of care. Significant differences were found between insured adults with a usual source of care, who were most likely to have received services, compared with uninsured adults without regular care, who were least likely to have received services. Those with either a usual source of care or insurance had intermediated levels of preventive services. CONCLUSIONS: Having a usual source of care and health insurance are both important to achieving national prevention goals.

  • Family Physicians' Solutions to Common Medical Errors

    One Pagers | Mar 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from “do not make errors” (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

  • Consequences of Medical Errors Observed by Family Physicians

    One Pagers | Mar 01, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

  • Types of Medical Errors Commonly Reported by Family Physicians

    One Pagers | Feb 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In a group of studies about medical errors in family medicine, the five error types most often observed and reported by U.S. family physicians were: (1) errors in prescribing medications; (2) errors in getting the right laboratory test done for the right patient at the right time; (3) filing system errors; (4) errors in dispensing medications; and (5) errors in responding to abnormal laboratory test results. “Errors in prescribing medications” was the only one of these five error types that was also commonly reported by family physicians in other countries.

  • Family Physicians Increase Provision of Well-Infant Care Despite Decline in Prenatal Services

    One Pagers | Jan 01, 2003 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD, MPH; Larry Green, PhD; Susan Dovey, MD, MPH; and Robert Phillips, MD, MSPH

    Over the past 20 years, both FP/GPs and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost half of their well-infant care. In fact, FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of FP training in pediatric medicine, preventive care, and child advocacy.

  • Family Physicians' Declining Contribution to Prenatal Care in the United States

    One Pagers | Dec 15, 2002 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD; Larry Green, MD; Susan Dovey, MD, MPH; Robert Phillips, MD, MSPH

    There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice.

  • Family Physicians Are the Main Source of Primary Health Care for the Medicare Population

    One Pagers | Dec 01, 2002 | James Mold, MD, MPH; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Susan Dovey, MD, MPH; Larry Green, MD

    Of people 65 years and older who reported an individual provider as their usual source of health care, 60 percent identified a family physician or general practitioner. The Medicare population relies heavily on family physicians.

  • Primary Care Research: Revisiting its Definition and Rationale

    Commentaries & Editorials | Mar 15, 2002 | Mold JW, Green LA

    Too often the questions of basic biomedical research have been mistaken to represent the critical scope of all medical research, and traditional laboratory methods have been seen as necessary and sufficient methods for understanding human health and illness. As a result, approximately 90% of National Institutes of Health (NIH) funding is spent on research within the traditional biomedical sciences (anatomy, biochemistry, genetics, microbiology, molecular biology, physiology, and so forth). The smaller amount of federal funding available for clinical research has been spent primarily on specific disease entities, such as cancer and heart disease. These funding decisions have resulted in the neglect of a large proportion of the problems and issues that confront primary care physicians and their patients.

  • The Role of Family Practice in Different Health Care Systems: A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States

    Articles | Jan 15, 2002 | Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H

    OBJECTIVE: Our goal was to compare the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions that are coded with or can be addressed by the International Classification of Primary Care (ICPC). STUDY DESIGN: In the Netherlands, Japan and Poland data were collected identically with an electronic patient record (Transhis). For all face-to-face encounters the reasons for encounter, diagnoses, and interventions were coded according to the ICPC within an episode of care structure; prescriptions were coded with the ICPC drug code. We derived comparable estimates for the United States using visit data from the National Ambulatory Care Survey (NAMCS), with specific emphasis on the contribution of family physicians. NAMCS data were mapped to the ICPC and the ICPC drug code, and Dutch, Polish, and Japanese data were directly standardized for the 1996 US population. Data on utilization, reasons for encounter, encounters per episode of care, new episodes of care, and prescriptions were compared. We also present World Health Organization and Organisation for Economic Co-operation and Development data on health care delivery, efficiency, expenditure, and health status for each country. RESULTS: We found important differences and striking similarities. Differences in the numbers of episodes and of encounters per patient per year were small compared with differences in utilization per episode of care, including diagnostic and therapeutic interventions. Substantial differences were found in prescribing antibiotics, oral contraceptives, cardiovascular medications, and gastrointestinal therapies. Prescribing behavior in the Netherlands and the United States are similar, while very different patterns were found in Japan and Poland. Similarities were much higher in patients’ reasons for encounter than in diagnoses. Only 35 groups of symptoms/complaints covered the top 30 in all databases, at the same time including 45% to 60% of all symptom/complaint reasons for encounter. The contribution of the US family physicians to care for common symptoms and episodes was generally high, but patients evidently also see other providers; the overall US distribution was similar to the Dutch data. With approximately 50 diagnoses, 45% to 60% of all new episodes of care were covered. Large differences existed in the contribution of family practice to gynecology/obstetrics and psychosocial problems. The proportion of all encounters per 1000 patients per year covered by the top 30 was 70% to 75%. CONCLUSION: Even under different conditions there was substantial overlap in the top 30 symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis in the 4 countries we studied. This striking resemblance supports the concept of the reason for encounter as a core element of the consultation with a family physician. Similarities between the databases are much better reflected by the way patients formulate their demand for care than in the diagnoses by the family physician. US patients also see providers other than family physicians for common problems; it remains unclear whether a limited group brings most of their health problems to a family physician or whether most people visit a series of primary care physicians. Possibilities to further develop episode-oriented epidemiology in family practice have considerably increased with this study. The potential for comparative studies has also increased with the introduction of complete electronic patient records based on the documentation of episodes of care with the ICPC and with its mapping to International Classification of Disease-10th revision (or the 9th revision clinical modification.)

  • Putting Practice into Research: A 20-Year Perspective

    Articles | Jun 01, 2000 | Larry Green, MD

    Since the 1982 article in Family Medicine focused on sentinel practices as an aspiration, practice based research networks (PBRNs) have become a fixture in the world of primary care. This perspectives piece reviews the origins and development of practice based research networks, their contribution to healthcare advancement, and their evolving role into the future.