Willingness to receive institutional and community-based eldercare among the rural elderly in China.

Studies on the willingness to receive institutional eldercare among the rural elderly are scarce. This study aims to explore factors associated with the willingness to receive institutional eldercare and community-based eldercare among the rural elderly. A cross-sectional study was conducted in three rural villages of Changde City, Hunan Province, China. A total of 517 elderly were recruited through multistage sampling from these villages. The dependent variable is the willingness to receive eldercare from family (as reference), institution, and community. The independent variables includes sociodemographic characteristics: having physical disease, depression, anxiety, and daily living activities, and concerns toward home-based, institutional, and community-based care, respectively. Results show that 78.3% of the elderly are willing to receive home-based eldercare, 10.8% institutional eldercare, and 8.5% community-based eldercare. The factors associated with the willingness to receive institutional eldercare are having concerns toward home-based (OR = 4.85, P<0.001) and institutional eldercare (OR = 5.51, P<0.001). The factors associated with community-based care is living alone (OR = 2.18, P = 0.034). Finally, the major concerns toward home-based eldercare are lack of care ability and separation of family members, whereas those toward institutional eldercare are unaffordable services and fear of being abandoned by the children. The major concerns toward community-based eldercare includes affordability and lack of necessary services. In summary, elderly having concerns toward home-based care and having no concerns about institutional care are willing to accept institutional eldercare. Elderly who are living alone is tend to accept community-based care. Unaffordable services and loss of contact with family members are the major concerns of institutional eldercare. Aside from the cost, the lack of necessary care services is also a serious concern of community-based eldercare.

A systematic review and novel classification of listing tools to improve medication in older people.

PURPOSE: Suboptimal drugs therapy is a threat to older people, and listing tools providing guidance are developed to address this problem. METHODS: A systematic review was performed to identify and analyze such tools published until February 2018. A novel categorization was developed to separate patient-in-focus listing approaches (PILA) providing disease-related positive and negative guidance from drug-oriented, mostly negative listing approaches (DOLA, DOLA+: with disease specification). RESULTS: In total, 76 tools were identified; only 9 were classified as PILA, 26 as DOLA, and 38 as DOLA+. Three DOLA(+) only address dementia. Most tools were developed in Europe or the USA and address community-dwellers. Thirty-two utilized a Delphi process, and only 10 provide a scoring system. Twenty tools utilize a questionnaire but no structured guidance or answers. Importantly, only 12 interventional clinical trials were identified reporting not only medication quality measures, but also clinical endpoints (e.g. falls, adverse drug reactions, hospitalization). For PILA, 4 trials showed positive, one negative clinical effects of a controlled intervention, for DOLA(+) 1 was positive, 7 negative (Fisher's exact test p < 0.05). DISCUSSION: An abundance of listing tools has been created. DOLAs that may be applied without intricate patient knowledge prevail over PILAs by sevenfold; unfortunately their clinical validation seems to be far less successful than that of patient-initiated approaches. CONCLUSION: Drug therapy in older people has to be tailored to their individual, very divergent needs; tools requiring detailed medical knowledge about the patient as the starting point for medication optimization provide the best support.

Qualidade de vida e autoestima em idosas submetidas e não submetidas à cirurgia estética / Quality of life and self-esteem in elderly patients who did or did not have cosmetic surgery

Introdução: A realidade do envelhecimento populacional chegou ao campo da Cirurgia Plástica, provada pelo crescimento do número de idosos que se submetem à cirurgia estética (CE). A pesquisa objetiva avaliar a importância da CE para o idoso, e se existe diferença de qualidade de vida e autoestima entre idosas que se submeteram e que não se submeteram à cirurgia estética. Métodos: Pesquisa casocontrole, sendo o grupo-caso formado por 25 idosas que se submeteram à CE e o grupo-controle por 25 idosas que não fizeram CE, pareados pelos dados socioeconômicos. Os instrumentos aplicados foram: Minimental, questionário de qualidade de vida (WHOQOL-BREF), escala de autoestima de Rosenberg e um questionário elaborado para pesquisa de dados sociodemográficos, motivação e satisfação com a CE. Resultados: A média de idade foi 67,26 anos e a escolaridade média, de 9,96 anos. As cirurgias mais realizadas foram a abdominoplastia e a blefaroplastia. Os motivos mais escolhidos foram o desconforto físico, o desejo de melhoria da qualidade de vida (QV) e a insatisfação com a autoimagem. Não foram encontradas idosas com baixa autoestima e o nível de satisfação foi alto quando relacionado com a própria vida ou a vida social. Não houve diferença de QV e autoestima entre os dois grupos analisados. Conclusão: As motivações das idosas para realização de CE são de ordem física e psicológica. Não houve diferença de QV e autoestima entre idosas submetidas e não submetidas à CE. Analisando-se as idosas submetidas à CE, foram comprovados altos níveis de satisfação pessoal e na vida social.

Introduction: The reality of aging has caught up with the field of plastic surgery, shown by the growth in the number of elderly patients who undergo cosmetic surgery (CS). To evaluate its importance in elderly women, this study examined differences in quality of life and self-esteem among those who did or did not undergo CS. Methods: This casecontrol study included 25 elderly women who underwent CS and a control group of 25 elderly women who did not undergo CS; the groups were matched by socioeconomic data. Assessment methods included the Mini-Mental State Examination, a quality of life (QOL) questionnaire (World Health Organization Quality of Life-Bref), the Rosenberg Self-Esteem Scale, and a questionnaire developed for the study of sociodemographic data, motivation, and satisfaction with CS. Results: The mean age was 67.26 years, with a mean of 9.96 years of education. The most common surgeries were abdominoplasty and blepharoplasty. The most common motivations were physical discomfort, desire to improve QOL, and dissatisfaction with self-image. No subjects were found to have low self-esteem and the level of satisfaction with personal or social life was high. There was no difference in QOL or self-esteem between the 2 groups. Conclusion: Physical and psychological motivations cause the elderly to undergo CS. There was no difference in QOL or self-esteem among elderly women who did or did not have CS. Elderly women who underwent CS showed high levels of satisfaction with their personal and social life.

Availability of services in registered retirement villages in Queensland, Australia: A content analysis.

OBJECTIVE: The study investigates and compares the services available in different types of registered retirement villages in Queensland (QLD). METHODS: A content analysis based on official websites of 175 registered villages in QLD, Australia, is presented. RESULTS: This study identifies 82 services, with activity organisation, emergency response, hairdressing and transportation being most frequently available to residents. The number of services available is associated with the village size and financial type, with residents living in large private villages having access to significantly more services. CONCLUSION: The research findings reveal the state of the art of current industry practice. They provide useful implications for stakeholders. For instance, residents who prefer to get access to various services should focus more on large private villages. Developers can check their service delivery environment to confirm its balance with residents' competencies. The government can propose innovative initiatives to promote the delivery of appropriate services in villages.

[Stability of home based care arrangements for people with dementia : Development of a consensus definition of stability using expert focus groups]. / Stabilität von häuslichen Versorgungsarrangements für Menschen mit Demenz : Entwicklung und Konsentierung einer Definition von Stabilität durch Expertenfokusgruppen.

BACKGROUND: The majority of people with dementia in Germany live at home. These informal care arrangements, which are mostly coordinated by informal carers, are the backbone of home-based dementia care. Creating and maintaining stability is an underlying theme in informal care; however, a definition of the complex phenomenon of 'stability' in this context is still lacking. AIM: The aim was to develop a working definition of stability of home-based care arrangements for people with dementia, which can be applied in current and future research projects at the German Center for Neurodegenerative Diseases in Witten (DZNE Witten) and others. MATERIAL AND METHODS: Ensuing from prior research a preliminary version of the definition was formulated. This definition was discussed in a focus group of scientific experts with expertise in dementia research and care (n = 8). After data analysis using content analysis, the definition was revised during a scientific colloquium (n = 18) and a consensus was finally reached. RESULTS: There were four major themes which were considered by the experts as being relevant for the definition of stability: (1) creating and maintaining stability as a continuous adaptation process, (2) a qualitative component of stability, (3) persons with dementia and informal carers as pivotal players and (4) transitions to residential care. CONCLUSION: The working definition introduced in this article reflects the authors' understanding of the phenomenon of stability of home-based care arrangements for people with dementia. In times of increasing need for evidence-based interventions it is necessary to develop elaborated definitions of complex phenomena in order to be able to systematically evaluate the efficacy of interventions on the basis of a common understanding.

Classification of Support Needs for Elderly Outpatients with Diabetes Who Live Alone.

OBJECTIVES: To investigate the support needs of elderly patients with diabetes and to classify elderly patients with diabetes living alone on the basis of support needs. METHODS: Support needs were derived from a literature review of relevant journals and interviews of outpatients as well as expert nurses in the field of diabetes to prepare a 45-item questionnaire. Each item was analyzed on a 4-point Likert scale. The study included 634 elderly patients with diabetes who were recruited from 3 hospitals in Japan. Exploratory factor analysis was performed to determine the underlying structure of support needs, followed by hierarchical cluster analysis to clarify the characteristics of patients living alone (n=104) who had common support needs. RESULTS: Exploratory factor analysis suggested a 5-factor solution with 23 items: (1) hope for class and gatherings, (2) hope for personal advice including emergency response, (3) supportlessness and hopelessness, (4) barriers to food preparation, (5) hope of safe medical therapy. The hierarchical cluster analysis of subjects yielded 7 clusters, including a no special-support needs group, a collective support group, a self-care support group, a personal-support focus group, a life-support group, a food-preparation support group and a healthcare-environment support group. CONCLUSIONS: The support needs of elderly patients with diabetes who live alone can be divided into 2 categories: life and self-care support. Implementation of these categories in outpatient-management programs in which contact time with patients is limited is important in the overall management of elderly patients with diabetes who are living alone.

Prevalence, Geographic Variation, and Trends in Hospital Services Relevant to the Care of Older Adults: Development of the Senior Care Services Scale and Examination of Measurement Properties.

BACKGROUND: The availability of hospital services for older adults nationwide is not well understood. OBJECTIVE: To present the development of the Senior Care Services Scale (SCSS) through: (1) identification of hospital services relevant to the care of older adults; (2) development of a taxonomy classifying these services; and (3) description of prevalence, geographic variation, and trends in service provision in US hospitals over time. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of US hospitals in 1999 and 2006 rounds of American Hospital Association Annual Survey of Hospitals (n=4998 and 4831 hospitals, respectively). Exploratory factor analysis was used to create the SCSS, and confirmatory factor analysis was used to examine services over time. The paper reports prevalence of services nationwide. RESULTS: The SCSS consisted of 2 service groups: (1) Inpatient Specialty Care (IP): geriatrics, palliative care, psychiatric geriatrics, pain management, social work, case management, rehabilitation, and hospice; and (2) Postacute Community Care (PA): skilled nursing, intermediate care, other long-term care, assisted living, retirement housing, adult day care, and home health services. Over time, hospitals offered more IP services and fewer PA services. The distribution of services did not mirror the distribution of where older adults reside in the United States. CONCLUSIONS: The development of the SCSS provides important information about senior care services before the passage of the Affordable Care Act. The apparent mismatch of hospital services and demographic trends suggests that many US hospitals may not provide a seamless continuum of care for an increasing population of older adults.

Characteristics of patients described as sub-acute in an acute care hospital.

Frail older patients suffer from multiple, complex needs that often go unmet in an acute care setting. Failure to recognize the geriatric giants in frail older adults is resulting in the misclassification of this population. This study investigated "sub-acute" frail, older-adult in-patients in a tertiary care teaching hospital. Although identified as being no longer acutely ill, all participants (n = 62) required active medical and/or nursing care. Frail older patients, often acutely ill, were being misclassified as sub-acute when the acuity of their illness went unrecognized which resulted in equally unrecognized disease presentations. The majority of participants wished to be cared for at or closer to home. The lack of post-acute-care service within our health care system and risk aversion on the part of hospital staff resulted in lengthy hospital stays and/or in patients being funneled into existing services (nursing homes) against their desire to go home.

[Development and validation of a scale aiming at measuring perceived patient-centered care by professionals]. / Développement et validation d'une échelle d'auto-évaluation des pratiques de bientraitance des patients ou des résidents par les professionnels de santé

OBJECTIVE: Patient-centered care is a concept recently implemented in French hospitals. No tools have been developing to measure patient-centeredness perceived by professional. The aim of the project was to develop and to validate a self-measure scale for healthcare providers. METHODS: The project has been conducting from June 2010 to June 2011. A multispecialty working group defined the conceptual framework (brainstorming, formalized consensus method), then built the questionnaire. After the pretest, the tool consisted in 44 items experimented in 35 shifts of 28 organizations. Exploratory and confirmatory psychometric properties were then tested (Principal component analysis, Cronbach' α coefficients, Structural equation modeling). RESULTS: Professional participation rate was 55%. The final solution produced a 16 items questionnaire and 3 dimensions (41,6% of the explained variance): Respect (5 items), Organisation (6 items), Patient and family information (5 items). Cronbach α coefficients were respectively 0,68, 0,83 and 0,68. CONCLUSION: This first patient-centered care scale developed in the French context had good psychometric properties. The questionnaire will be tested another time next year in order to comfort our results and to explore jointly the patient perceptions of patient-centered care.

Classification of emergency departments according to their services for community-dwelling seniors.

OBJECTIVES: The goal was to develop a classification of emergency departments (EDs) based on their organization of services for seniors discharged to the community. METHODS: This was a secondary analysis of data collected in a survey of key informants (chief physicians and head nurses) in EDs in Quebec on the organization of services for community-dwelling seniors discharged to the community. Organizational characteristics were classified a priori in the following three categories: 1) availability of human resources, 2) care processes, and 3) links to community services. A multifactorial analysis (MFA) was used to analyze the variables by category and globally, thus investigating not only the relationships between variables within each category, but also the relationships between different categories. The authors then proceeded to classify EDs using Ward's method (hierarchical ascendant classification) applied to reduced data dimensions. RESULTS: The sample consisted of 103 EDs. Analyses were carried out on data from the 68 (66%) of these EDs that supplied complete data. These 68 EDs did not differ in terms of their size or geographical location from the 35 other departments that supplied incomplete or no data. We identified three groups of EDs: most specialized (with regard to internal staff and care processes) and less community-oriented (n = 12), moderately specialized and less community-oriented (n = 28), and least specialized and more community-oriented (n = 28). CONCLUSIONS: This classification of EDs with respect to their organization of services for community-dwelling seniors may be helpful to those planning services, to decision-makers, and to researchers. The three groups of EDs identified in this study represent three types of organizations with differing assets and limitations. The generalizability of these groups to other settings and the implications for patient outcomes should be investigated.

Optimizing communication between medical professionals and people living with dementia.

BACKGROUND: A growing body of research evidence indicates that improving communication with people living with dementia (PLWD) has a positive effect on their quality of life. Policy initiatives internationally highlight the prevalence of poor communication practices in care environments in general and medical contexts in particular as priority areas for improvement. Currently available communication interventions exhibit shortcomings, and their application remains unusual. METHODS: A spectrum of multidisciplinary professional and lay stakeholders, including PLWD, took part in an iterative consultation process in the UK. This aimed to develop a communications advice package which would meet their needs, and involved observation of practice in a variety of care contexts and semi-structured focus group and individual interviews. RESULTS: Lay participants reported dissatisfaction with current communicative practices, particularly during contact with medical professionals. Both lay and professional participants reported general dissatisfaction with currently available communication advice. An agreed version of a dementia toolkit for effective communication (DEMTEC) was produced. This consists of three "levels". The foundation Level 1 details beliefs about the psychosocial effects of dementia on communication, as well as empowering approaches to communication involving PLWD. Level 2 consists of practical considerations and advice in eight key areas. Level 3 uses case studies to show how the principles and advice in preceding levels are applicable to individuals in different care contexts and at different stages of dementia. CONCLUSION: The project has produced a free-to-users instrument that is empirically supported and adaptable to individual PLWD and to a range of health, care and sociocultural environments.

[Detection of temporomandibular joint diseases in elderly and senile age in ambulatory medicoprophylactic institutions].

The research analyzes diagnostic TMJ's disease's identification work of stomalogists owned to different types of day care properties (municipal, departmental, private). This research based on examination of primary medical records of 1906 patients aged 61 to 89 years, including 2978 prescribing lists made by stomatologists - orthopedists to dental outpatient's card. This research shows that in case of outpatient conditions in the primary examination of patients of elderly and senile age stomatologists pay attention to joint pathology in the presence of acute patients' complaints, caused by TMJ's displacement, arthritis, painful TMJ's dysfunction or pronounced sound phenomena of TMJ. Stomatologists examine TMJ's pathology more particularly. The TMJ's pathology complicates the tooth replacement made to patients contrary to absence of indications of disease presence in primary medical records. The prepared conclusion and recommendations allow improving the outpatient diagnosis of TMJ's pathology.

Does geography matter? The health service use and unmet health care needs of older Canadians.

The rising cost of health care and changing demographic profiles have resulted in the relocation and redistribution of funding and services between rural and urban areas. Most econometric analyses of Canada's health service use include broad controls by province and rural/urban status, but relatively little econometric work has focused on geographical variation in health service use. Using the Canadian Community Health Survey 2.1, we examined determinants of various measures of health services use by Canadians aged 55 or older across a range of urban and rural areas of residence. Our regression analysis showed that older residents in rural areas made fewer visits to a general practitioner, to a specialist, and to a dentist relative to urban residents. All else being equal, there are no significant differences in hospital nights or in unmet healthcare needs. These differences are significant after controlling for demographic characteristics, socioeconomic status, private health insurance, and health status.

The interface between residential aged care and the emergency department: a systematic review.

BACKGROUND: emergency care for older people living in residential aged care facilities (RACF) is a complex area of health policy. The epidemiology of patient transfer between RACF and hospital emergency departments (ED), clinical outcomes and costs associated with transfer and efficacy of programs aiming to reduce transfer are not well known. DESIGN: systematic review based on a comprehensive literature search in three electronic databases and published article reference lists. RESULTS: the incidence of transfer from RACF to ED is >30 transfers/100 RACF beds/year in most studies. The casemix from RACF is varied and reflects that of the broad elderly population, with some risk difference. At least 40% of transfers are not admitted to hospital. There is insufficient data to fully address our other questions; however, hospitalisations from RACF can be reduced through advanced care planning, use of management guidelines for acute illnesses and improved primary care. CONCLUSIONS: residents of RACF have a high annual risk of transfer to ED. The clinical benefit and cost effectiveness of ED care, and alternate programs to reduce ED transfer, cannot be confidently compared from published work. Further research is required to accurately describe these and to determine their comparative worth.

Qualidade de vida e capacidade funcional de idosos adscritos em um PSF da cidade de Cruz Alta/RS / Quality of life and functional capacity of elderly people enrolled in a family health program in Cruz Alta/RS

O objetivo deste estudo foi comparar a qualidade de vida entre idosos autônomos e dependentes vinculados ao PSF de um bairro da cidade de Cruz Alta/RS e identificar a existência de associação entre a idade, o gênero e a avaliação subjetiva de saúde com a capacidade funcional. Foram avaliados 103 idosos com idade média de 70,8 anos (73 por cento mulheres e 27 por cento homens). Os instrumentos usados para avaliação da capacidade funcional foram o índice de Barthel e a escala de Lawton e para avaliação da qualidade de vida, o WHOQOL-bref. A associação entre as variáveis foi estimada através do coeficiente de correlação de Pearson e através do teste do qui-quadrado. As diferenças eventuais entre as médias dos sujeitos foram estimadas através do teste t de Student. Na determinação da capacidade funcional, foram classificados 65 idosos como autônomos e 38 como dependentes. Não foi identificada associação entre a capacidade funcional e o gênero (p = 0,16). Porém houve associação entre a capacidade funcional e a idade (p = 0,000) e a avaliação subjetiva de saúde (p = 0,007). Na comparação das médias dos domínios do WHOQOL-bref entre o grupo autônomo e dependente, foi encontrada diferença significativa em todos os domínios e na qualidade de vida global. Ao final, os resultados indicaram que nos idosos que referiram uma pior avaliação subjetiva da condição da saúde há também maior dependência.

The aim of this study was to compare the quality of life among autonomous and dependent elderly people enrolled in a Family Health Program (FHP) in a district of Cruz Alta, Rio Grande do Sul, Brazil and to identify the existence of an association among age, gender and health subjective evaluation with functional capacity. One hundred and three elderly people averaging 70.8 years old (73 percent female and 27 percent male) were evaluated. The instruments used to evaluate the physical capacity were the Barthel index and Lawton’s Scale, and WHOQOL-bref to evaluate quality of life. Association among the variables was estimated through the Pearson correlation coefficient and through the chi-square test. Eventual differences among the averages of the subjects were estimated through the t Student test. In order to determine the functional capacity, 65 elderly were classified as autonomous and 38 as dependent. It was not identified association between functional capacity and gender (p = 0.16), but there was an association between functional capacity and age (p = 0.000) and the subjective health evaluation (p = 0.007). When comparing the WHOQOL-bref dominion averages between autonomous and dependent groups, a significant difference was found in all dominions and in global quality of life. In conclusion, results indicated that in those elderly people who referred a worse health condition in the subjective evaluation, the dependence is greater.

Prediction of care class by local additive reference to prototypical examples.

The public long-term care insurance program for the elderly in Japan set out in 2000 toward establishing a new system whereby citizens can be assured that they will receive care and be supported by the society as a whole. The insurance program includes computer-aided certification processes to estimate the needs for nursing care for clients. In this work, we show the applicability of an adaptive local nonlinear approximation method associated with the Japanese national database for automatic inference of the care class.

[Ambulatory geriatric rehabilitation and its legal classification within the statutory health insurance system]. / Ambulante geriatrische Rehabilitation und ihre leistungsrechtliche Einordnung in die gesetzliche Krankenversicherung.

In Germany, the number and proportion of elderly people will continue to increase. Only few hospitals and rehabilitation units are currently providing inpatient geriatric services. Concepts for graded geriatric care see ambulatory geriatric rehabilitation (AGR) as an independent service und as a complement to pre-existing structures in geriatric care. In 2004, the national association of statutory health insurance funds established recommendations for AGR, which include criteria of structural and process quality of ambulant geriatric rehabilitation. This article describes various aspects of these framework recommendations (target groups, rehabilitation indicators, and equipment of services). In addition, the classification of AGR within the legislation of the statutory health insurance system is evaluated. The financing of AGR by the statutory health insurance system and the preconditions for accreditation of AGR-services within this system are discussed. The authors conclude that discrimination between existing partially-inpatient day clinics and AGR services is not appropriate. Furthermore, there is no legal basis for such a discrimination; on the contrary, the terms partially-inpatient and ambulatory rehabilitation services can be seen as a uniform benefit according to book 5 of the German social code, SGB V. Therefore there is no differentiation between AGR and partially-inpatient rehabilitation in the statutory health insurance system.

Does age influence the intensity of care in a managed care organization?

The primary objective of this study was to determine whether an inverse relationship between age and the intensity of care prevailed in an elderly, functionally impaired population enrolled in a managed care organization. The secondary objective was to determine whether those who died during the study were treated more intensively than the survivors. A total of 278 enrollees in a managed care organization who were 75 years and over, had a severe functional disability, excessive hospital or Emergency Department use, volunteered to take part in a 2-year study. Seventy-seven clients died during the study. We calculated indices of outpatient care intensity and hospital care intensity for the study period. With minor exceptions, the results clearly show that, for this group of clients, the intensity of outpatient care was clearly, inversely related to age. The intensity of hospital care was also inversely related to age, thereby ruling out the hypothesis that it was being substituted for outpatient care. The results also clearly show that, for this population, those who died during the study period were treated more intensively than the survivors. We found strong support for our hypotheses. An investigation of the reasons for these findings was beyond the scope of our data.

Utilization of services among elderly cancer patients--relationship to age, symptoms, physical functioning, comorbidity, and survival status.

In this study we investigated predictors of utilization of primary care physician, hospital and emergency room services in a sample of 909 older patients during the first year following a diagnosis of cancer of the breast, colon, lung, or prostate. Analysis of covariance models were implemented separately for the active treatment period (0-6 months) and the continuing care period (6-12 months) to determine how age, sex, comorbidity, length of survival, treatment status, stage of disease, cancer site, physical functioning, and symptom count were related to primary care physician visits, hospitalization, and emergency room use. Decreased physical functioning was related to increased physician visits, hospital nights, and emergency room visits during the active treatment period, and to increased hospital nights and emergency room visits during the continuing care period. Patients with three or more comorbid conditions reported more physician visits than patients with no comorbid conditions during both periods. Patient age did not play a significant role in utilization of services. The broad picture suggested by this study of elderly cancer patients is that their service utilization, particularly hospitalization and emergency room services, tends to peak in concert with a dramatic decrease in physical functioning as the patient nears the end of life. Use of primary care physicians' services may depend substantially on comorbid conditions.