Barbara Starfield

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States

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Publications (286)1770.21 Total impact

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    ABSTRACT: China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training. Copyright © 2013 John Wiley & Sons, Ltd.
    International Journal of Health Planning and Management 04/2013; · 0.97 Impact Factor
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    ABSTRACT: To determine the validity and reliability of the version of the Primary Care Assessment Tool for adult users, adapted for Argentina (known as AR-PCAT-AE). Two cross-sectional pilot studies were conducted among people over age 17, largely through self-administered questionnaires. Items that were equivalent to the original version of the PCAT and 13 others proposed for the instruments were analyzed. The factorial validity and reliability of the scores for each dimension were studied. The validity indicators were: factors that had three or more items with a factorial load of > 0.35, item-total correlation > 0.30, and interpretation of the solution according to the theoretical model. The factorial analysis yielded nine factors that explained 57.4% of the variability. Considering the pre-established criteria for validity, two items were excluded from the dimensions of continuity and comprehensiveness and six were added to comprehensiveness and cultural competency. In the dimensions, the percentage of questions with an item-total correlation of greater than 0.30 ranged from 67% to 100% and the Chronbach's (alpha) coefficient of internal consistency ranged from 0.44 to 0.90. The validity and reliability of the AR-PCAT-AE questionnaire are adequate, maintaining high equivalence with the original version. The process presented could be adopted in other contexts to advance the evaluation of primary health care functions with quality tools.
    Revista Panamericana de Salud Pública 01/2013; 33(1):30-9. · 0.85 Impact Factor
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    ABSTRACT: BACKGROUND: There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. OBJECTIVE: Assessing the primary care development in Austria. METHODS: A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). RESULTS: Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. CONCLUSION: This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.
    Family Practice 11/2012; · 1.84 Impact Factor
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    ABSTRACT: OBJECTIVE: To obtain versions of the Primary Care Assessment Tools (PCAT)-Facility version to evaluate primary care (PC) in the Spanish context, and to analyze its feasibility, reliability and validity. METHODS: Cultural adaptation was performed through the use of forward and backward translations into Spanish and Catalan, observations and opinions of a panel of experts, and cognitive interviews with target users (PC team managers). A pilot phase was carried out in a sample of 130 managers of PC teams in Catalonia. A post-test questionnaire was sent 4-5 months later to all 194 managers of PC teams in the Barcelona health region. Analysis of metric properties included: 1) description of items and verification of Likert assumptions, since domain scores are obtained by summing item scores; 2) reliability analysis (Cronbach's alpha coefficient, Pearson's correlation coefficient, test-retest analysis); and 3) validity analysis (expert panel, cognitive interviews, and convergent and discriminant validity). RESULTS: Substantial adaptation was required for the accessory section of the questionnaire, but less was required in PC domain measurements. Items were added to the comprehensiveness domain to reflect services usually available in Spain. The lowest Cronbach's alpha scores were found for Access (0.62) and Coordination (0.59 and 0.65), while values were >0.70 for the remaining domains. CONCLUSION: The Spanish version of the PCAT-Facility questionnaire is now available and shows adequate reliability and validity. The Spanish PCAT version will facilitate national and international comparisons of PC and analysis of the determinants of quality of service provision.
    Gaceta Sanitaria 08/2012; · 1.25 Impact Factor
  • Barbara Starfield
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    ABSTRACT: As of 2005, the literature on the benefits of primary care oriented health systems was consistent in showing greater effectiveness, greater efficiency, and greater equity. In the ensuing five years, nothing changed that conclusion, but there is now greater understanding of the mechanisms by which the benefits of primary care are achieved. We now know that, within certain bounds, neither the wealth of a country nor the total number of health personnel are related to health levels. What counts is the existence of key features of health policy (Primary Health Care): universal financial coverage under government control or regulation, attempts to distribute resources equitably, comprehensiveness of services, and low or no copayments for primary care services. All of these, in combination, produce better primary care: greater first contact access and use, more person-focused care over time, greater range of services available and provided when needed, and coordination of care. The evidence is no longer confined mainly to industrialized countries, as new studies show it to be the case in middle and lower income countries. The endorsements of the World Health Organization (in the form of the reports of the Commission on Social Determinants of Health and the World Health Report of 2008, as well a number of other international commissions, reflect the widespread acceptance of the importance of primary health care. Primary health care can now be measured and assessed; all innovations and enhancements in it must serve its essential features in order to be useful.
    Gaceta Sanitaria 03/2012; 26 Suppl 1:20-6. · 1.25 Impact Factor
  • Barbara Starfield
    Medical care 11/2011; 49(11):971-2. · 2.94 Impact Factor
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    ABSTRACT: Objectives Primary care (PC) paediatricians are trained mainly in the hospital setting, with little contact with PC. This study aimed to find out what perceptions and experiences they have on the attributes of PC (first contact, comprehensiveness and continuity of care) that are assumed and performed by PC paediatricians.
    Anales de Pediatría 10/2011; 75(4):247-252. · 0.72 Impact Factor
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    Barbara Starfield, Karen Kinder
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    ABSTRACT: Multimorbidity is increasing in frequency. It can be quantitatively measured and is a major correlate of high use of health services resources of all types, especially over time. The ACG System for characterizing multimorbidity is the only widely used method that is based on combinations of different TYPES of diagnoses over time, rather than the presence or absence of particular conditions or numbers of conditions. It incorporates administrative data (as from claims forms or medical records) on all types of encounters and is not limited to diagnoses captured during hospitalizations or other places of encounter. It can be employed in any one or combination of analytic models, and can incorporate medication use if desired. It is being used in clinical care, management of health services resources, in health services research to control for degree of morbidity, and in understanding morbidity patterns over time. In addition to its research uses, it is being employed in many countries in various applications as a policy to better understand health needs of populations and tailor health services resources to health needs.
    Health Policy 09/2011; 103(1):3-8. · 1.73 Impact Factor
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    ABSTRACT: To assess the reliability and validity of the Spanish version of the CHIP-CE/CRF. Cross-sectional study was conducted in a representative sample of primary school children in Spain. Children were administered the Spanish version of the CHIP-CE/CRF. The Achenbach Child Behavioral Checklist was given to parents. The overall response rate was 75% (n = 979). Internal consistency was >0.70 for 3 out of 5 domains, and the intraclass correlation coefficient for test-retest stability ranged from 0.69 to 0.80. Confirmatory factor analysis replicated the original model. Younger children scored higher in Satisfaction than older children. Girls scored lower in Comfort but higher in Risk Avoidance than boys. The Spanish version of the CHIP-CE/CRF has shown acceptable reliability and validity, similar to the properties of the original US version. Future studies should analyze the instrument's sensitivity to change.
    Quality of Life Research 08/2011; 21(5):909-14. · 2.86 Impact Factor
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    ABSTRACT: Primary care (PC) paediatricians are trained mainly in the hospital setting, with little contact with PC. This study aimed to find out what perceptions and experiences they have on the attributes of PC (first contact, comprehensiveness and continuity of care) that are assumed and performed by PC paediatricians. A qualitative study was performed based on focus groups and semi-structured individual interviews with paediatricians with pre-defined sociodemographic and speciality training characteristics. Two focus groups (5 and 4 people each) and 5 interviews were made. Participants responded to two questions: how would you explain your function as a primary care paediatrician? and what is your opinion on the relationship between primary care paediatricians and the specialists to whom your patients are referred? The conversations of the groups and interviews were recorded and transcribed, and a content analysis was performed. Paediatricians assume that PC must be comprehensive, and take into account the context of the child. Paediatricians declare a lack in their training and poor social and institutional recognition. Coordination with specialists and the transfer of information are not satisfactory. Helpful factors are personal knowledge, the shared training and the face-to-face clinical sessions. Despite their hospital-based training, paediatricians assume the attributes of PC. Difficulties in performing their function include poor adaptation of their training to PC, and little institutional and social recognition. Coordination with specialists is not satisfactory. Approaching these difficulties can help maintaining a high quality level in the care of the paediatric population.
    Anales de Pediatría 08/2011; 75(4):247-52. · 0.87 Impact Factor
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    Barbara Starfield
    Journal of epidemiology and community health 08/2011; 65(8):653-5. · 3.04 Impact Factor
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    Barbara Starfield
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    ABSTRACT: Both patient-centered and person-focused care are important, but they are different. In contrast to patient-centered care (at least as described in the current literature with assessments that are visit-based), person-focused care is based on accumulated knowledge of people, which provides the basis for better recognition of health problems and needs over time and facilitates appropriate care for these needs in the context of other needs. That is, it specifically focuses on the whole person. Proposed enhancements and innovations to primary care do not appear to address person-focused care. Tools to assess person-focused care are available and deserve more widespread use in primary care.
    The Permanente journal 05/2011; 15(2):63-9.
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    B Starfield, J Gérvas, D Mangin
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    ABSTRACT: Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
    Annual Review of Public Health 04/2011; 33:89-106. · 3.27 Impact Factor
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    ABSTRACT: ABSTRACT: June 2010 marked the 10th Anniversary of the foundation meeting of the International Society for Equity in Health (ISEqH). he formation of the Society was a bold statement, with ambitions to be a global body "to promote equity in health and health services internationally through education, research, publication, communication and charitable support"[1]. The Society particularly aimed to be an organisation that facilitated research on how better to understand and address inequities in health. The main activities of the Society have been a series of biannual conferences as well as the establishment of the International Journal for Equity in Health, the official (but independent) publication of the Society. This paper sets out to record some of the milestones of the Society drawing on the reflections of key researchers who attended the conferences as well as others. The history of the Society will help shape its future and how it responds to important issues facing all interested in global efforts to address continuing and unacceptable inequities in health.
    International Journal for Equity in Health 02/2011; 10:11. · 1.71 Impact Factor
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    Barbara Starfield
    International Journal for Equity in Health 01/2011; 10:15. · 1.71 Impact Factor
  • Barbara Starfield
    Primary Health Care Research & Development 01/2011; 12(1):1-2.
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    ABSTRACT: The Primary Care Assessment Tool (PCAT) is an interesting set of tools for primary care research. A very short version could inform policy makers about consumer experiences with primary care (PC) through health surveys. This work aimed to investigate the validity and reliability of a selection of items from the child short edition (CS) of the PCAT. A 24 item questionnaire permitted the identification of a regular source of care and the assessment of the key attributes of first contact, ongoing care over time, coordination, services available and services received (comprehensiveness), and cultural competence. Structural validity, reliability, and construct validity were assessed using responses from 2,200 parents of a representative sample of the population aged 0 to 14 years in Catalonia (Spain) who participated in the 2006 Health Survey. Structural validity was analyzed using exploratory and confirmatory factor analyses and reliability was assessed using Cronbach's alpha. Construct validity was assessed using linear regression analysis between PC experience scores and a measure of overall user satisfaction with healthcare services. A total of 2,095 (95.2%) parents provided useable responses on PC. After Confirmatory Factor Analysis (CFA), the best fitting model was a 5-factor model in which the original dimensions of first contact and ongoing care were collapsed into one. The CFA also showed a second order factor onto which all domains except services available loaded (root mean square error of approximation = 0.000; comparative fit index = 1.00). Cronbach's alpha values for one of the original scales (first-contact) was poor (alpha < 0.50), but improved using the modified factor structure (alpha > 0.70). Scores on the scales were correlated with satisfaction with healthcare services (p < 0.01), thereby providing some preliminary evidence of construct validity. This very short questionnaire obtained from the PCAT-CE yields information about five attributes of PC and a summary score. It has shown evidence of validity and reliability for judgments about experiences with primary care overall. If space on surveys is at a premium, the instrument could be useful as a measure of PC experiences.
    BMC Public Health 01/2011; 11:285. · 2.32 Impact Factor
  • B. Starfield, D Mangin
    01/2011: pages 147-155.; Radcliffe.
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    Barbara Starfield
    Journal of General Internal Medicine 08/2010; 25(8):758-9. · 3.42 Impact Factor
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    Barbara Starfield
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    ABSTRACT: Canada is, in many respects, culturally and economically similar to the United States, and until relatively recently, the two countries had similar health systems. However, since passage of the Canada Health Act in the 1970s, that nation's health statistics have become increasingly superior. Although the costs of Canada's health system are high by international standards, they are much lower than U.S. costs. This paper describes several factors likely to be responsible for Canada's better health at lower cost: universal financial coverage through a so-called single payer; features conducive to a strong primary care infrastructure; and provincial autonomy under general principles set by national law.
    Health Affairs 05/2010; 29(5):1030-6. · 4.64 Impact Factor

Publication Stats

10k Citations
1,770.21 Total Impact Points


  • 1971–2013
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Health Policy and Management
      Baltimore, Maryland, United States
  • 1968–2013
    • Johns Hopkins University
      • Department of Pediatrics
      Baltimore, Maryland, United States
  • 2011
    • University of Melbourne
      Melbourne, Victoria, Australia
  • 2010
    • The Chinese University of Hong Kong
      • The Jockey Club School of Public Health and Primary Care
      Hong Kong, Hong Kong
  • 2009
    • University of Amsterdam
      • Faculty of Medicine AMC
      Amsterdam, North Holland, Netherlands
    • The University of Manchester
      Manchester, England, United Kingdom
  • 2008
    • St George's, University of London
      Londinium, England, United Kingdom
  • 2007
    • Philadelphia University
      Philadelphia, Pennsylvania, United States
    • The Children's Hospital of Philadelphia
      • Department of Pediatrics
      Philadelphia, PA, United States
    • Agència de Salut Pública de Barcelona
      Barcino, Catalonia, Spain
  • 1991–2007
    • Johns Hopkins Medicine
      • Department of Health Policy and Management
      Baltimore, Maryland, United States
  • 2005
    • University of Otago
      • Wellington School of Medicine and Health Sciences
      Dunedin, Otago, New Zealand
  • 1999–2005
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 2003–2004
    • Fundação Oswaldo Cruz
      Rio de Janeiro, Rio de Janeiro, Brazil
  • 2001
    • Rochester General Hospital
      • Division of Pediatrics
      Rochester, NY, United States
  • 1996
    • Consorcio Hospital General Universitario de Valencia
      • Departamento de Pediatría
      Valencia, Valencia, Spain
  • 1993
    • University of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 1988
    • University of California, San Francisco
      • Institute for Health Policy Studies
      San Francisco, CA, United States