July/August 2009 Annals of Family Medicine...( The Primary Care Paradox and the Ne...),Health

The Primary Care Paradox and the Need to Integrate Primary and Specialty Care to Improve the Quality of Healthcare
The third in a seven-part series of commentaries to understand health and healthcare

With the healthcare reform debate heating up in Washington, D.C., Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., continues his seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and improving healthcare and health. The July/August issue of the Annals features the series' third installment, which explores the paradox of primary care the fact that when compared with specialty care, primary care is associated with poorer quality care for individual diseases, yet higher value health care at the level of the whole person, and better health, greater equity, lower costs and better quality of care at the level of populations.

Stange warns that current solutions to improving quality may do more harm than good if they focus more on diseases than on people because efforts to improve the parts (evidence-based care of specific diseases) may not necessarily improve the whole (the health of people and populations). He contends that our current system undervalues care at the level of the whole-person and community, resulting in adverse consequences for the cost, effectiveness and equity of health care. He calls for systems of care that foster the integration of generalist and specialist care both horizontally for individuals, communities and populations, and vertically for specific diseases.

The Paradox of Primary Care
By Kurt C. Stange, M.D., Ph.D.
Case Western Reserve University, Ohio

Chronic Disease Care Better in Community Health Centers and Practices with Nurse-Practitioners

Analyzing the impact of different primary care models and practice features on chronic disease management, researchers in Ontario, Canada found t
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