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Barbara Starfield

In Memory of Barbara Starfield

The Johns Hopkins Primary Care Policy Center deeply mourns the untimely loss of our founding director, Dr. Barbara Starfield, and offers condolences to her family and friends everywhere. 

Dr. Starfield was the founding director of the Johns Hopkins University Primary Care Policy Center (PCPC). With her leadership, the Johns Hopkins PCPC has achieved the following notable distinctions:

  • Contributions specifically pertinent to the work of health centers. The Johns Hopkins team has produced the most literature on the nation’s vulnerable populations, in particular health centers (HCs) that serve vulnerable populations, including their sustainability, provider recruitment and retention experiences, financial performance, experience under managed care, preventive care services, quality of care, and comparisons with other health care settings.
  • Contributions to knowledge and policy concerning primary care. The PCPC team has conducted pioneering research on the association between primary care and health outcomes, the role of primary care in reducing social inequities, and more particularly on the role of primary care in mediating the adverse impact of income inequality on health outcomes, in collaboration with BPHC colleagues and other national experts. Studies have been conducted using US state, MSA, county, and individual level data. The promotion of primary care is one potential policy strategy to improve health, even in the face of marked disparity in the distribution of income. The Johns Hopkins team has been involved in the development and validation of the adult-, child-, and practice/facility-specific primary care assessment tools that capture the principal domains of primary care. These tools can be used to study primary care experience rendered under different health care systems or settings and for patients with different sociodemographic attributes. They can be used with other outcomes to assess the effect of policy interventions and systems changes on the delivery of critical aspects of primary care.
  • The Johns Hopkins team has a strong and nationally known clinical expertise. Not only are the core PCPC faculty primary care clinicians and researchers, we have access to nationally known clinical researchers of all specialties. With its strong clinical expertise and ACG technology, the Johns Hopkins team is uniquely positioned to study health center patients and compare them appropriately with national patients.
  • The PCPC has worked extensively with both health center data sets and other national sources of data. These include survey data, health services data, and population data on health and resources. Intimate knowledge of these data sets makes it possible to conduct comparative analyses and extend analyses to include other relevant characteristics relating to health. 
  • The contributions achieved in collaboration with the BPHC have relevance far beyond their pertinence to the work of HCs. Research and analyses using health center data, both by themselves and by comparison with other types of sources of care, contribute to decision making throughout the US as well as abroad.

Dr. Starfield was Johns Hopkins University Distinguished Service Professor with appointments in the Departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine.

Dr. Starfield's overriding concerns were understanding the impact of health services on health, especially with regard to the relative contributions of primary care and specialty care on reducing inequities in health. Her focus was both on clinical care and on services to populations as well as the inter-relationships between the two. Trained in Pediatrics and Epidemiology, she devoted her energies to health services research and its translation into health policy at the national, state, and local levels. Her specific research interests were in primary care measurement, the relationship between the processes and outcomes of health care, quality of care, health status measurement (particularly for adolescents and children), and child health policy. Dr. Starfield was a member of the Institute of Medicine. She was the recipient of numerous national awards, including the first Pew Primary Care Research Award (1994), the Distinguished Investigator Award of the Association for Health Services Research (1995) and the American Public Health Association’s Martha May Eliot Award (1995). Dr. Starfield was named an Honorary Fellow of the Royal College of General Practitioners (UK) in 2000 and received the Ambulatory Pediatric Association’s Lifetime Achievement Award in 2002; in 2004, she was awarded the Baxter International Foundation Prize for Health Services Research. She also received the John G. Walsh Award for Lifetime Contributions to Family Medicine (2005), the Avedis Donabedian Award for Leadership in Quality of Care (2006), and the Avedis Donabedian Award for Quality Improvement (2007).

Dr. Starfield's work has involved the development of methods to measure primary care, health status in children, and ambulatory case-mix. Her book on Effectiveness of Medical Care: Validating Clinical Wisdom, summarizes what is known about the impact of access to care on children's health; it focuses heavily on the problems of access for low-income children and the effect of the Medicaid program on access and health. Her book entitled Primary Care: Concept, Evaluation, and Policy (Oxford University Press, 1992) summarizes what is known about the impact of primary care within a health services system as well as an approach that is useful for examining the extent of primary care in populations and in clinical facilities. Her 1998 landmark book, Primary Care: Balancing Health Needs, Services, and Technology, provides innovative methods to evaluate the attainment and contributions of primary care systems and practitioners. It complements the earlier book by highlighting two additional areas: equity in health services and health, and overlap between clinical medicine and public health. It provides an important basis for future directions in health policy. Dr. Starfield's work in developing a method to measure ambulatory case mix has applications for both management and research since it provides a basis for prospective payment and a means of standardizing or controlling for differences in patient's health status in administrative and research efforts.

Barbara Starfield was the founding editor of the International Journal for Equity in Health and a co-founder and first president of the International Society for Equity in Health.

Dr. Starfield’s most recent editorial conveys the themes she has promoted uncompromisingly throughout her career - equity in health and health care, person focused view of morbidity, and the central role of primary care providers:

"A 'whole-patient oriented' view of disease is more accurate than a disease oriented view. It is also more equitable. Diseases are more likely to occur and to be more serious in socially disadvantaged people ... Only a person-focused (rather than a disease-focused) view of morbidity, in which multiple illnesses interact in myriad ways, can accurately depict the much greater impact of illness among socially disadvantaged people and the nature of the interventions that are required to adequately manage the increased vulnerability to and interactions among diseases."

"Inequity is built into health systems - especially western health systems that are based on a view of health needs disease-by disease. Therefore, the benefits of primary care, which is person- and population- rather than disease-focused, are underappreciated. Data provide evidence not only of its benefit to populations but also of its preferential benefit to the socially disadvantaged. Increasing referral rates from primary care to specialty care pose a special problem for socially deprived population groups, as their greater morbidity leads them to be referred to more different types of specialists with consequent increased likelihood of poor coordination, adverse effects, and unnecessarily high costs (some which will come from out-of-pocket payments) unless there is strong primary care ... Primary care must inevitably assume increasing importance in health systems because it is far superior in dealing with multimorbidity over time. This is part of the explanation for its greater contribution to health in modern societies."

A decade ago Barbara wrote what we, researchers in the field of health equity, can strive to follow (Starfield B. Is equity a scientific issue? West J Med 2000 July; 173 (1): 7.)

"The subject of the causation of inequities in health is clearly complex, but it is amenable to scientific study. The many issues concerning the nature of the pathways in different population groups, in different cohorts, and indifferent historical time periods are only some of the many challenges. We need good scientific research on the nature of the pathways and their consistency and variability; on the best ways to specify the variables that represent the various types of characteristics in the theoretical models; on the relative influence and mechanisms of effect of various types of interventions to reduce the effects on ill health and, perhaps, even improve the health of populations ; and on the special challenges posed by vulnerable population groups, such as children and adolescents, women and especially pregnant women, and racial and ethnic minorities. The development and application of statistical techniques that elucidate mechanisms rather than describe them are also a high priority, as are collaborative efforts across political jurisdictions and countries to improve the generalizability of research results and policy applications."


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