Socioeconomic disparities in the use and success of fertility treatments: analysis of data from a prospective cohort in the United States.

OBJECTIVE: To determine the effect of income, education, and race on the use and outcomes of infertility care. DESIGN: Prospective cohort. SETTING: Eight community and academic infertility practices. PATIENT(S): Three hundred ninety-one women presenting for an infertility evaluation. INTERVENTION(S): Face-to-face and telephone interviews and questionnaires. MAIN OUTCOME MEASURE(S): Use of infertility services and odds of pregnancy. Linear and logistic regression used to assess relationship between racial and socioeconomic characteristics, use of infertility services, and infertility outcomes. RESULT(S): After adjustment for age and demographic and fertility characteristics, college-educated couples (ß = $5,786) and households earning $100,000-$150,000 (ß = $6,465) and ≥$150,000 (ß = $8,602) spent significantly more on infertility care than their non-college-educated, lower-income counterparts. Higher income and college-educated couples were much more likely to use more cycles of higher-intensity fertility treatment. The increased cost of infertility care was primarily explained by these differences in number and type of infertility treatment. Even after adjustment for these factors and total amount spent on fertility care, having a college degree was associated with persistently higher odds of achieving a pregnancy (OR = 1.9). CONCLUSION(S): Education and household income were independently associated with the amount of money spent on fertility care. This relationship was primarily explained by types and intensity of infertility treatments used. Having at least a college degree was independently associated with improved odds of pregnancy.

Costs of infertility treatment: results from an 18-month prospective cohort study.

OBJECTIVE: To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued. DESIGN: Prospective cohort study in which women were followed for 18 months. SETTING: Eight infertility practices. PATIENT(S): Three hundred ninety-eight women recruited from infertility practices. INTERVENTION(S): Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used. MAIN OUTCOME MEASURE(S): Per-person and per-successful-outcome costs. RESULT(S): Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not. CONCLUSION(S): Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment.

Are the uninsured responsible for the increase in emergency department visits in the United States?

STUDY OBJECTIVE: The rise in emergency department (ED) use in the United States is frequently attributed to increased visits by the uninsured. We determine whether insurance status is associated with the increase in ED visits. METHODS: Using the national Community Tracking Study Household Surveys from 1996 to 1997, 1998 to 1999, 2000 to 2001, and 2003 to 2004, we determined for each period the proportion of reported adult ED visits according to insurance status, family income, usual source of care, health status, and outpatient (non-ED) visits. Trends over time were tested for statistical significance. RESULTS: The proportion of adult ED visits by persons without insurance was stable across the decade. Uninsured individuals accounted for 15.5% of ED visits in 1996 to 1997, 16.1% in 1998 to 1999, 15.2% in 2000 to 2001, and 14.5% of visits in 2003 to 2004 (P for trend=.43). The proportion of visits by persons whose family income was greater than 400% of the federal poverty level increased from 21.9% to 29.0% (P=.002). The proportion of visits by those whose usual source of care was a physician's office increased from 52.4% in 1996 to 1997 to 59.0% in 2003 to 2004 (P=.002), whereas the proportion of visits by those without a usual source of care was essentially unchanged (9.7% of visits in 1996 to 1997 and 9.6% in 2003 to 2004; P=.74). CONCLUSION: The rise in ED visits between 1996 and 2003 cannot be primarily attributed to the uninsured. Major contributors to increasing ED utilization appear to be disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office.

Pilot trial of a computerized decision aid for breast cancer prevention.

This study sought to evaluate a shared decision-making aid for breast cancer prevention care designed to help women make appropriate prevention decisions by presenting information about risk in context. The decision aid was implemented in a high-risk breast cancer prevention program and pilot-tested in a randomized clinical trial comparing standard consultations to use of the decision aid. Physicians completed training with the decision aid prior to enrollment. Thirty participants enrolled (15 per group) and completed measures of clinical feasibility and effectiveness prior to, immediately after, and at 9 months after their consultations. The decision aid was feasible to use during the consultations as measured by consultation duration, user satisfaction, patient knowledge, and decisional conflict. The mean consultation duration was not significantly different between groups (24 minutes for intervention group versus 21 minutes for control group, p = 0.42). The majority found the decision aid acceptable and useful and would recommend it to others. Both groups showed an improvement in breast cancer prevention knowledge postvisit, which was significant in the intervention group (p = 0.01) but not the control group (p = 0.13). However, the knowledge scores returned to baseline at follow-up in both groups. Decision preference for patients who chose chemoprevention post consultations remained constant at follow-up for the intervention group, but not for the control group. The decision framework provides access to key information during consultations and facilitates the integration of emerging biomarkers in this setting. Initial results suggest that the decision aid is feasible for use in the consultation room. The tendency for the decision choices and knowledge scores to return to baseline at follow-up suggests the need for initial and ongoing prevention decision support.

Characteristics of frequent users of emergency departments.

STUDY OBJECTIVE: We identify frequent users of the emergency department (ED) and determine the characteristics of these patients. METHODS: Using the 2000 to 2001 population-based, nationally representative Community Tracking Study Household Survey, we determined the number of adults (aged 18 and older) making 1 to 7 or more ED visits and the number of visits for which they accounted. Based on the distribution of visits, we established a definition for frequent user of 4 or more visits. Multivariate analysis assessed the likelihood that individuals with specific characteristics used the ED more frequently. RESULTS: An estimated 45.2 million adults had 1 or more ED visits. Overall, 92% of adult users made 3 or fewer visits, accounting for 72% of all adult ED visits; the 8% of users with 4 or more visits were responsible for 28% of adult ED visits. Most frequent users had health insurance (84%) and a usual source of care (81%). Characteristics independently associated with frequent use included poor physical health (odds ratio [OR] 2.54; 95% confidence interval [CI] 2.08 to 3.10), poor mental health (OR 1.70; 95% CI 1.42 to 2.02), greater than or equal to 5 outpatient visits annually (OR 3.02; 95% CI 1.94 to 4.71), and family income below the poverty threshold (OR 2.36; 95% CI 1.70 to 3.28). Uninsured individuals were more likely to report frequent use, but this result was only marginally significant (OR 2.38; 95% CI 0.99 to 5.74). Individuals who lacked a usual source of care were actually less likely to be frequent users. CONCLUSION: The majority of adults who use the ED frequently have insurance and a usual source of care but are more likely than less frequent users to be in poor health and require medical attention. Additional support systems and better access to alternative sites of care would have the benefit of improving the health of these individuals and may help to reduce ED use.

Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms) trial.

OBJECTIVE: This study was undertaken to compare resource use outcomes for participants in the Medicine or Surgery (Ms) randomized trial. STUDY DESIGN: In a randomized controlled trial, we compared resources used during a 24-month follow-up period by women with abnormal uterine bleeding who were randomly assigned to either expanded medical treatment or hysterectomy. RESULTS: Women randomly assigned to hysterectomy used significantly more resources (medicine = $4479, hysterectomy = $6777; P = .03), with almost all the difference caused by the hysterectomy procedure. Fifty-three percent of women randomly assigned to medicine had a hysterectomy during the follow-up period; women who were able to continue on medical therapy had mean total resource use of $2595 compared with $6128 for medicine patients who eventually had surgery. CONCLUSION: For women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate, compared with expanded medical treatment, hysterectomy increases resource use significantly and results in better clinical and 6-month quality-of-life outcomes.

The relationship of insurance status, hospital ownership, and teaching status with interhospital transfers in California in 2000.

PURPOSE: Public hospitals and academic medical centers may admit more poorly insured transfer patients than do other institutions. The authors investigated the relationship of patient insurance status, hospital ownership, and hospital teaching status with interhospital transfers in California. METHOD: In 2003, data were derived from the hospital discharge abstract database for the year 2000 from the California Office of Statewide Health Planning and Development. Hospitals were categorized by ownership and teaching status; patients were categorized as being "good" or "poor" payers depending on the level of expected insurance reimbursement. Descriptive and multivariate analyses were used to assess the number of poor payer transfers admitted by each hospital group. RESULTS: In 2000, there were 58,509 transfer and 2,320,479 direct admissions. All hospital groups admitted a higher percentage of good payer than poor payer transfer patients (85% vs. 15% respectively for all groups combined). Adjusted for total number of admissions and teaching status, the number of poor payer transfer patients admitted to county-owned and University of California hospitals was significantly higher than the statewide average (both p values < .001), while the number admitted to independent teaching hospitals was significantly lower than the statewide average (p < .001). The number of poor payer transfer patients admitted to independent teaching hospitals more closely resembled that of for-profit hospitals than that of University of California teaching hospitals. CONCLUSIONS: In 2000, the likelihood of a hospital admitting a transfer patient appears to have been affected by both the patient's insurance status and the hospital's ownership. In general, good payer patients were more likely to be transferred than were poor payer patients, with poor payer transfer patients more likely to be admitted to publicly owned hospitals.

Sexual functioning after total compared with supracervical hysterectomy: a randomized trial.

OBJECTIVE: To compare sexual functioning and health-related quality-of-life outcomes of total abdominal hysterectomy (TAH) and supracervical hysterectomy (SCH) among women with symptomatic uterine leiomyomata or abnormal uterine bleeding refractory to hormonal management. METHODS: We randomly assigned 135 women scheduled to undergo abdominal hysterectomy in 4 U.S. clinical centers to either a total or supracervical procedure. The primary outcome was sexual functioning at 2 years, as assessed by the Medical Outcomes Study Sexual Problems Scale. Secondary outcomes included specific aspects of sexual functioning and health-related quality-of-life at 6 months and 2 years. RESULTS: Sexual problems improved dramatically in both randomized groups during the first 6 months and plateaued by 1 year. Health-related quality-of-life scores also improved in both groups. At 2 years, both groups reported few problems with sexual functioning (mean score on the Sexual Problems Scale for SCH group 82, TAH group 80, on a 0-to-100 scale with 100 indicating an absence of problems; difference = +2.95% confidence interval -8 to +11), and there were no significant differences between groups. CONCLUSION: Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients.

Hospital resource utilization for primary and revision total hip arthroplasty.

BACKGROUND: Previous reports have suggested that hospital resource utilization for revision total hip arthroplasty is substantially higher than that for primary total hip arthroplasty. However, current United States Medicare hospital-reimbursement policy does not distinguish between the two procedures. The purpose of this study was to compare primary and revision total hip arthroplasties with regard to actual hospital resource utilization and to identify clinical and demographic factors that are predictive of higher resource utilization associated with these procedures. METHODS: We evaluated the clinical, demographic, and economic data associated with 491 consecutive unilateral primary or revision total hip arthroplasties performed by two surgeons at a single institution between January 2000 and December 2002. The distributions of various demographic, clinical, and utilization characteristics were compared between the two types of arthroplasty procedures, and multivariable linear regression techniques were used to determine independent patient characteristics that were predictive of higher costs for both the primary and the revision procedures. RESULTS: The mean total hospital cost was $31,341 for the revision procedures compared with $24,170 for the primary procedures (p < 0.0001). The mean operative time was 41% longer for the revisions than for the primary procedures (4.5 hours compared with 3.2 hours, p < 0.0001), the mean estimated blood loss was 160% higher (1348 mL compared with 518 mL, p < 0.0001), the mean complication rate was 32% higher (29% compared with 22%, p = 0.072), and the mean length of the hospital stay was 16% longer (6.5 days compared with 5.6 days, p = 0.0005). A higher severity-of-illness score (a measure of preoperative medical health) was predictive of higher resource utilization for both primary and revision arthroplasty even after adjustment for other factors. Preoperative femoral and ace-tabular bone loss and a diagnosis of periprosthetic fracture were predictive of higher resource utilization associated with revision procedures. CONCLUSIONS: At one institution, hospital resource utilization for revision total hip arthroplasty was found to be significantly higher than that for primary arthroplasty. This information is not reflected by current United States Medicare hospital reimbursement, which is the same for all lower-extremity arthroplasty procedures, regardless of the diagnosis, the complexity of the procedure, or the patient's baseline medical health. If these findings are generalizable to other institutions, appropriate reimbursement formulas should be developed to accurately reflect the true costs of caring for patients with a failed total hip arthroplasty.

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study.

STUDY OBJECTIVE: We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit. METHODS: This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year. RESULTS: Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use. CONCLUSION: ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

Resource use for total and supracervical hysterectomies: results of a randomized trial.

OBJECTIVE: Hysterectomy is the most common major surgical procedure performed in the United States for nonobstetric reasons. Although most hysterectomies include removal of the cervix, the rate of supracervical procedures has increased in recent years. To provide evidence about the outcomes of both types of hysterectomy, we conducted a randomized clinical trial of total (TAH) or supracervical (SCH) hysterectomy (the "TOSH" trial). We report here an analysis of 24-month resource use by patients in this trial. METHODS: A randomized controlled trial was performed at 3 clinical centers to compare resources used by 120 patients who received a total or supracervical abdominal hysterectomy. Service use during a 24-month follow-up period was identified from medical and billing records and patient reports. Each service used was assigned a relative value, which was then converted into 2002 U.S. dollars. RESULTS: Overall resource use was similar in the 2 study groups in the first 12 months after randomization (TAH 5,870 US dollars; SCH 6,018 US dollars; 95% confidence interval for difference -960 US dollars, 1,255 US dollars; P <.79) and for the full 24 months (TAH 6,448 US dollars; SCH 7,479 US dollars; 95% confidence interval for difference -533 US dollars, 2,616 US dollars; P <.20). In exploratory multivariable analyses, resource use was significantly associated with baseline body mass index greater than or equal to 35 kg/m(2) (8,440 US dollars versus 6,398 US dollars, P =.02) and heavy bleeding (7,550 US dollars versus 5,368 US dollars, P =.02). CONCLUSION: We conclude that the use of medical care resources over a 24-month period is comparable for total and supracervical hysterectomy. The association of a woman's weight and bleeding pattern with subsequent resource use requires further investigation.

Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical outcomes in the medicine or surgery trial.

OBJECTIVE: To compare clinical outcomes after randomization to hysterectomy versus medical treatment in patients with chronic abnormal uterine bleeding refractory to medroxyprogesterone acetate. METHODS: We randomly assigned 63 premenopausal women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate treatment to receive either a hysterectomy or expanded medical treatment. Within each randomized group, the specific treatment approach was determined by patient and provider preference. The primary analysis compared changes in clinical outcomes at 6 and 24 months by using an intention-to-treat approach. Secondary as-treated analyses after adjustment for baseline covariates compared participants randomly assigned to medical treatment who continued the medical approach with those who crossed over to hysterectomy. RESULTS: The intention-to-treat analyses at 6 months revealed greater symptom improvement in the hysterectomy group than in the medicine group for pelvic pain (P <.01), urinary urgency (P =.03), incomplete bladder emptying (P =.03), breast pain (P =.02), and cessation of vaginal bleeding (87% versus 11%, P <.001). Seventeen of 32 women assigned to medicine (53%) eventually crossed over and received a hysterectomy, and by 24 months the statistically significant differences by intention-to-treat were limited to greater improvement in hot flushes (P <.01) and cessation of vaginal bleeding (P <.01). Within-group analyses at year 2 showed statistically significant improvements from baseline on most symptoms for women who had a hysterectomy, whether through randomization or crossover. Women remaining on medical treatments had statistically significant improvements in pelvic pain, pelvic/bladder pressure, and stress incontinence. In a nonrandomized comparison with women who remained on medical treatments through year 2, those crossing over to hysterectomy experienced greater improvements in bleeding (P <.01), pelvic pain (P <.01), low back pain (P =.02), breast pain (P =.01), urinary frequency (P =.01), and urgency (P =.02). However, they also experienced more days off from work or usual activities (P <.01) and more days spent in bed (P <.01) than those who remained on medicine. CONCLUSION: For patients with abnormal uterine bleeding refractory to medroxyprogesterone acetate, hysterectomy is superior to expanded efforts with oral medications for alleviating clinical symptoms but may lead to more days of restricted activity.

Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: the medicine or surgery (Ms) randomized trial.

CONTEXT: Although a quarter of US women undergo elective hysterectomy before menopause, controlled trials that evaluate the benefits and harms are lacking. OBJECTIVE: To compare the effect of hysterectomy vs expanded medical treatment on health-related quality of life. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, randomized controlled trial (August 1997-December 2000) of 63 premenopausal women, aged 30 to 50 years, with abnormal uterine bleeding for a median of 4 years who were dissatisfied with medical treatments, including medroxyprogesterone acetate. The participants, who were patients at gynecology clinics and affiliated practices of 4 US academic medical centers, were followed up for 2 years. INTERVENTIONS: Participants were randomly assigned to undergo hysterectomy or expanded medical treatment with estrogen and/or progesterone and/or a prostaglandin synthetase inhibitor. The hysterectomy route and medical regimen were determined by the participating gynecologist. MAIN OUTCOME MEASURES: The primary outcome was mental health measured by the Mental Component Summary (MCS) of the 36-Item Short-Form Health Survey (SF-36). Secondary outcomes included physical health measured by the Physical Component Summary (PCS), symptom resolution and satisfaction, body image, and sexual functioning, as well as other aspects of mental health and general health perceptions. RESULTS: At 6 months, women in the hysterectomy group had greater improvement in MCS scores than women in the medicine group (8 vs 2, P =.04). They also had greater improvement in symptom resolution (75 vs 29, P<.001), symptom satisfaction (44 vs 7, P<.001), interference with sex (41 vs 22, P =.003), sexual desire (21 vs 3, P =.01), health distress (33 vs 13, P =.009), sleep problems (13 vs 1, P =.03), overall health (12 vs 2, P =.006), and satisfaction with health (31 vs 14, P =.01). By the end of the study, 17 (53%) of the women in the medicine group had requested and received hysterectomy, and these women reported improvements in quality-of-life outcomes during the 2 years that were similar to those reported by women randomized to the hysterectomy group. Women who continued medical treatment also reported some improvements (P<.001 for within-group change in many outcomes), with the result that most differences between randomized groups at the end of the study were no longer statistically significant in the intention-to-treat analysis. CONCLUSIONS: Among women with abnormal uterine bleeding and dissatisfaction with medroxyprogesterone, hysterectomy was superior to expanded medical treatment for improving health-related quality-of-life after 6 months. With longer follow-up, half the women randomized to medicine elected to undergo hysterectomy, with similar and lasting quality-of-life improvements; those who continued medical treatment also reported some improvements.

A randomized comparison of total or supracervical hysterectomy: surgical complications and clinical outcomes.

OBJECTIVE: To compare surgical complications and clinical outcomes after total versus supracervical abdominal hysterectomy for control of abnormal uterine bleeding, symptomatic uterine leiomyomata, or both. METHODS: We conducted a randomized intervention trial in four US clinical centers among 135 patients who had abdominal hysterectomy for symptomatic uterine leiomyomata, abnormal uterine bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a total or supracervical hysterectomy performed using the surgeon's customary technique. Using an intention-to-treat approach, we compared surgical complications and clinical outcomes for 2 years after randomization. RESULTS: Sixty-eight participants were assigned to supracervical hysterectomy (SCH) and 67 to total abdominal hysterectomy (TAH). Hysterectomy by either technique led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain, urinary incontinence, and voiding dysfunction. Patients randomly assigned to (SCH) tended to have more hospital readmissions than those randomized to TAH, but this difference was not statistically significant. There were no statistically significant differences in the rate of complications, degree of symptom improvement, or activity limitation. Participants weighing more than 100 kg at study entry were twice as likely to be readmitted to the hospital during the 2-year follow-up period (relative risk [RR] 2.18, 95% confidence interval [CI] 1.06, 4.48, P=.034). CONCLUSION: We found no statistically significant differences between (SCH) and TAH in surgical complications and clinical outcomes during 2 years of follow-up.

Primary care at a crossroads.

In response to concerns about the future of primary care, the Robert Wood Johnson Foundation sponsored a meeting in October 2001 in Glen Cove, New York, of 45 leaders in primary care and other health sectors. The purpose was to discuss the current and future challenges to primary care and to develop new and innovative ideas about how primary care might meet the needs of our current and future population. The premise of the meeting was that primary care is at a crossroads, which could lead to a new renaissance or a continued decline. Principles and ideas need to be identified to construct new primary care systems. As background for the meeting, 15 papers were written by experts in health care policy and primary care. Included in this supplement are revised versions of 4 of these papers, which present an overview of the current crisis, the implications of patients' views of primary care, the Chronic Illness Model as one possible solution, and a prediction of a tiering in the way primary care is delivered in the future. The final paper presents ideas and suggestions, based in part on the discussions at the meeting, about opportunities to move toward another renaissance of primary care.

Primary care medicine in crisis: toward reconstruction and renewal.

Primary care is in crisis. Despite its proud history and theoretical advantages, the field has failed to hold its own among medical specialties. While the rest of medicine promises technology and sophistication, the basic model of primary care has changed little over the past half-century. Why has the transition from general practice to today's primary care been so difficult? Many of the causes of this struggle may lie within primary care itself, ranging from failure to articulate to the public (and insurers and policymakers) what value it, and it alone, can offer, to taking on an ever-broadening set of roles and responsibilities while all too often falling short of its promises. Perhaps most important, in the emerging health care system, the lack of a discrete definition of primary care has allowed managed care organizations and payers, among others, to define the role of primary care to suit their own interests. In response to a changing marketplace, political uncertainty, and shifting consumer expectations, primary care will need to reconstruct itself. The reconstruction will not be easy. Nevertheless, a process should begin that moves the field in the right direction. Building on its unique abilities, primary care can emerge as a redefined product that is attractive to patients, payers, and primary care practitioners alike.

Primary care: the next renaissance.

Three decades ago, a renaissance helped create the foundations of primary care as we know it today. In recent years, however, new challenges have confronted primary care. We believe that the current challenges can be overcome and may, in fact, present an opportunity for a new renaissance of primary care to address the needs of our population. In this paper, we suggest seven core principles and a set of actions that will support a renaissance in, and a positive future for, primary care. The seven principles are 1) Health care must be organized to serve the needs of patients; 2) the goal of primary care systems should be the delivery of the highest-quality care as documented by measurable outcomes; 3) information and information systems are the backbone of the primary care process; 4) current health care systems must be reconstructed; 5) the health care financing system must support excellent primary care practice; 6) primary care education must be revitalized, with an emphasis on new delivery models and training in sites that deliver excellent primary care; and 7) the value of primary care practice must be continually improved, documented, and communicated. At the start of the 21st century, a vital, patient-centered primary care system has much to offer a rapidly changing population with increasingly diverse needs and expectations. If we keep the needs of persons and patients clearly in sight and design systems to meet those needs, primary care will thrive and our patients will be well served.