Better questions about access to and use of services are required to obtain more adequate information about types of care needed and received. This requires an understanding of the relative importance of primary care and specialty care, to improve the quality of decisions on personnel training, resource distribution, and financing and organization of services.
A continuing imperative is to improve methods and measures for all services. Clinical measures of quality that are based on evidence from various types of research studies are developing at a relatively rapid pace, but efforts to develop measures of health services performance are not. Recent research has demonstrated that the quality of systems for delivering primary care for children can be assessed using criteria that are widely accepted as constituting good primary care. These are based on characteristics including accessibility for first-contact care, person-focused care over time, comprehensiveness of care, and coordination of care when people have to be seen elsewhere (Cassady et al., 2000; Starfield et al., 1998). However, there has been little movement to incorporate primary care measures into existing data collection efforts. Moreover, there has been no effort to develop ways of conceptualizing and assessing the adequacy of specialty care services. Recent research is showing the variable nature of need for specialty services, including the need for advice and guidance, confirmation of initial opinion, and need for definitive interventions that can be provided only at the specialty level (Forrest, Glade, Baker, Bocian, Kang, and Starfield, 1999; Forrest, Rebok, Riley, Starfield, Green, Robertson, and Tambor, 2001) Both national and international data indicate great variability in referral rates from primary care to specialists and from one cultural context to another (Forrest, Majeed, Weiner, Carroll, and Bindman, 2002a). Although much of this variability can be attributed to age and case-mix differences, considerable variability remains even after controlling for these characteristics. Moreover, there is consistent and robust evidence of gaps in coordination of care, even though better coordination has been demonstrated to improve at least some aspects of the results of care (Forrest, Glade, Baker, von Schrader, and Starfield, 2000). Thus, for policy-related measures to be available and adequate, policy makers need to encourage and support efforts to develop criteria for referral and then to develop evidence-based guidelines to monitor rates of referral in different areas and in different population subgroups to ensure the most effective and equitable use of health services personnel and resources.
To capture the performance of both the personal health care system and the public health system, allow systematic assessment across the range of different performance attributes, and consider disparities in the distribution of services across various populations, an integrated measurement system should adopt a broad set of performance categories. As illustrated in Table 5-2, these categories include the effectiveness, efficiency, availability, appropriateness, capability, safety,