Obesity Treatment in Primary Care — Are We There Yet?

Weightloss pyramid.Image via Wikipedia

The U.S. Preventive Services Task Force recommends that clinicians arrange for their obese patients to receive intensive, multicomponent behavioral weight-loss counseling.1 However, less than 50% of primary care physicians (PCPs) report that they consistently provide diet and weight-control advice to their adult patients with weight-related disease, and less than 25% regularly refer patients for further management or track their weight-control behaviors over time.2
Recognizing the need for effective weight-management treatments that can be implemented in the primary care setting, the National Heart, Lung, and Blood Institute funded the Practice-based Opportunities for Weight Reduction consortium,3 a group of independent but coordinated comparative-effectiveness trials of weight-loss interventions delivered in primary care settings to obese patients with cardiovascular risk factors. The primary outcome was weight change at 2 years. In this issue of the Journal, the results of two of these studies4,5 are presented.
In the study by Wadden et al.,4 usual care (counseling provided at quarterly PCP office visits) was compared with the addition of brief lifestyle counseling (monthly, 15-minute, in-person counseling visits by trained medical assistants) and with enhanced lifestyle counseling (brief lifestyle counseling plus a toolbox that included meal replacements and weight-loss medications). Although weight loss in the brief-lifestyle-counseling group (2.9 kg) and the usual-care group (1.7 kg) did not differ significantly at 2 years, participants in the enhanced-lifestyle-counseling group lost significantly more weight (4.6 kg) than did those in either of the other two groups and were more likely to lose at least 5% of their initial body weight (35% in the enhanced-lifestyle-counseling group, vs. 26% in the brief-lifestyle-counseling group and 22% in the usual-care group).
In the study by Appel et al.,5 participants from six primary care practices were randomly assigned to a self-directed weight-loss program (control group); to in-person individual sessions plus group sessions, along with electronic and telephone contacts delivered by office-based lifestyle coaches (in-person support); or to a commercial call center–directed group in which coaches delivered all lifestyle interventions by telephone, Internet, and e-mail (remote support). Physicians supported the delivery of the interventions, reviewed participants’ weight status, and at routine medical visits encouraged participants to be engaged with the weight-loss treatment. Weight loss at 2 years was similar in the groups that received in-person support (5.1 kg) and remote support (4.5 kg) and was significantly greater than the weight loss in the control group (0.8 kg). Participants assigned to either the in-person or the remote lifestyle intervention were twice as likely as those assigned to the control group to have lost 5% or more of their initial body weight at 2 years (41% for the in-person group and 38% for the remote group, vs. 19% for the control group).
A well-recognized issue that affects the sustainability of behavioral interventions is that attendance at face-to-face counseling sessions decreases substantially over time. In the study by Wadden et al., participants in both the brief-lifestyle-counseling and the enhanced-lifestyle-counseling groups attended fewer than half the scheduled counseling visits during year 2. Similarly, in the study by Appel et al., those assigned to the in-person group participated in only 2 of 24 recommended face-to-face individual and group sessions between month 7 and the end of the trial. In contrast, those assigned to the remote group participated in a median of 16 of 18 recommended telephone contacts during that time. Given that remotely delivered coaching resulted in weight-loss outcomes similar to those of in-person visits, the use of mobile technologies to deliver behavioral weight-loss treatment in primary care appears to be promising. Such interventions may present fewer barriers to adherence than interventions delivered in person, since they allow for greater scheduling flexibility, decreased travel time, and lower transportation costs. In addition, a telephone-based coaching program has the potential for widespread implementation in multiple practice settings, including geographically isolated areas.
Both these studies provide evidence that PCPs can deliver safe and effective weight-loss interventions in primary care settings. However, there are important caveats. Although described as “effectiveness” rather than “efficacy” studies, both studies provided treatments (including lifestyle coaching, counseling, and, in the case of the Wadden study, meal replacements and medications) at no cost to the participants. Whether patients would be willing to pay for these therapies, or insurers would be willing to reimburse for them, is not known. Determining the costs and cost-effectiveness of these and other treatments in primary care settings is crucial. In addition, these two studies were not powered to detect differences in cardiovascular risk reduction, and there were no consistent between-group differences with respect to lipid levels, glucose levels, or blood pressure at 2 years. Particularly when one is augmenting behavioral treatments with medication, it is critical to assess the impact of such interventions on obesity-related coexisting conditions.
Finally, although more than one third of patients may respond to lifestyle counseling with weight loss of at least 5% of their baseline weight, many obese persons do not successfully achieve or maintain weight losses sufficient to improve their health by means of lifestyle changes alone. Some patients will require additional treatments (e.g., medications or bariatric surgery) as an adjunct to, but not a replacement for, lifestyle interventions. Continued research on ways to enhance patients’ adherence to long-term lifestyle changes should improve the reach and effectiveness of behavioral treatments for obesity in primary care settings.
The opinions expressed herein are those of the author and do not necessarily reflect the views of the National Institutes of Health or the Department of Health and Human Services.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMe1111487) was published on November 15, 2011, at NEJM.org.


From the Office of Obesity Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.

David Pencheon: Good general practice is sustainable general practice and vice versa

Source: BMJ blogs

2 Nov, 11 | by BMJ Group
David Pencheon
Once again the RCGP’s Annual conference last week in Liverpool produced a wealth of stimulating and topical debates – from the ethics of whether doctors should take a lead in commissioning (why do we always feel the need to “take the lead?”), to what constitutes sustainable general practice. The groups considering the latter issue, chaired by Tim Ballard and Trevor Thompson, concluded that when done well general practice and primary care is, by its very nature, sustainable: keeping people healthy, independent, empowered, and out of hospital. However, these worthy aspirations don’t always inspire and direct individuals to more specific action. Of course, there is the usual list of ways in which we can do the day job in a more environmentally sensitive way: declutter, go even more paperless, measure and reduce energy consumption, more teleconsultations (did I hear correctly that one Cornish practice has exceeded 50% here?), better procurement, fewer and more integrated collection of specimens, visits on foot, by bike, on a (electric) scooter.
However, the group felt that if we really wanted to be truly sustainable, there should be a focus on the models of care for its population that really would keep people healthy, independent, empowered, and out of hospital. What was needed, the group felt, was a specific list of clinical and health related areas where significant action (or research if necessary) should be commissioned and/or implemented. What are the known knowns (or even the known unknowns) where systematic and exemplary action would have the most effect to immediate and long term patient care and population health? 
Five areas emerged, neatly summarised by Peter Cawston, a GP from Glasgow:
  1. Helping people eat better and move better (where some of the most significant co-benefits for health can be made. Over eating red processed meat is not good for immediate health or for longer term environmental survival and the use of fossil fuel to travel is good neither for our own health nor our children’s – as well as being dangerously carbon intensive).
  2. Enabling women to have control over their fertility (especially pertinent as we welcome the 7 billionth citizen to the planet).
  3. Targeting prescribing on those most likely to benefit (in particular moving from target driven medication lists to therapy tailored to the individual, with consequent improvements in safety and effectiveness as well as reductions in financial and environmental costs arising from the manufacture and use of drugs).
  4. Promoting a greater sense of belonging (helping people to connect more and consume less, building on the personal trusting relationships at the core of general practice).
  5. Helping people manage a better death (where the avoidance of death and promotion of longevity as signs of success need to be recalibrated to what is a much more humane and dignified approach to helping people manage their end of life, and end of life care).
David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).

SIAP 2011: Quaternary prevention

Prévention quaternaire

Quaternary prevention

Marc Jamoulle, Charleroi, Belgium
Family doctor
Free lance researcher in Primary care

WICC member

Seminario Internacional/ Seminaire international
/International Seminaire / Seminário Internacional

Barcelona (Spain), Sunday 2nd October 2011 (09.00am to 03.00 pm)
download program & instructions     Access to the SIAP 2011 Yahoo group

  Personal citations      //    Bibliography (.pdf)    //      Zotero shared bibliography    //     First draft

MUS_quaternary 2005_permission to Be Illhttp://d1.scribdassets.com/ScribdViewer.swf?document_id=67396541&access_key=key-1x1lrl6zzzsjgbbq5ld0&page=1&viewMode=list

Si no tiene médico de cabecera, peligra su salud !

Juan Gérvas                                      Image via Wikipedia*¿NO TIENE MÉDICO DE CABECERA? *



Juan Gérvas y Mercedes Pérez Fernández, médicos generales rurales,
Equipo CESCA, Madrid, España_


Usted y su familia están en peligro si no tienen un médico de cabecera, si no tienen tienen un médico que coordine los cuidados de otros médicos.

El médico de cabecera es el “agente” del paciente, y decide como si fuera el propio paciente. Es decir, decide junto al paciente con el conocimiento de un médico especialista en problemas frecuentes, y en el conjunto de problemas de la persona (en su entorno familiar, laboral, cultural y social).

El médico de cabecera es ese médico “de siempre”, el que entra en casa y
cuenta con la confianza de quien conoce vida, milagros y secretos del paciente, la familia y la comunidad. Es el médico cercano y conocido, con una amplia formación científica, con conocimientos, corazón y coraje.

Está demostrado que el médico de cabecera decide mejor que el propio
paciente para elegir especialistas y momento de la atención (y, también,
cuándo se necesitan cuidados urgentes).

El médico de cabecera se ocupa directamente de los problemas frecuentes y coordina los cuidados de los especialistas para los problemas infrecuentes.

Necesitamos médicos especialistas, pero hay que utilizarlos con prudencia, pues su “exceso de uso” es peligroso para la salud. Está demostrado que cuanto más especialistas haya en una zona geográfica, mayor mortalidad se produce.

Cada especialista puede ofrecer cuidados excepcionales, cuidados de excelente calidad, pero la intervención de varios especialistas no coordinados es peligrosa para la salud. Por ello, en los EEUU la salud es la peor y la más cara (comparada con los demás países desarrollados). Por ejemplo, en los EEUU las amputaciones en pacientes diabéticos son el triple que la media en los países desarrollados.

En los EEUU la tercera causa de muerte es la actividad de los médicos.

No faltan buenos especialistas en los EEUU. Faltan médicos de cabecera que coordinen los cuidados, que actúen de agentes de los pacientes.

Por ejemplo, un pediatra es especialista en enfermedades de los niños, no en los niños situados en su entorno familiar, escolar, cultural y social. Lo mismo sucede con un ginecólogo respecto a la mujer. O con un geriatra respecto a los ancianos. O con un urólogo respecto al varón. Todos estos especialistas deberían actuar como consultores del médico de cabecera, y éste debería coordinar sus consejos y tratamientos para “adaptarlos” al paciente en su conjunto, de forma que produzcan más beneficios que daños.

Todos los pacientes necesitan un médico cabecera que coordine los necesarios cuidados de los especialistas.

Además, el médico de cabecera es muy accesible, flexible, polivalente y resolutivo. Lo mismo le ayuda frente a la gripe que hace una biopsia de piel, coloca un DIU, vacuna contra el sarampión, visita al niño con
parálisis cerebral en su casa, aconseja frente a una jubilación, trata una tuberculosis, asesora frente al insomnio, hace un análisis de orina ante un cistitis, o trata con morfina al paciente terminal y le ayuda a enfrentarse con dignidad a la muerte en domicilio. Todo ello teniendo en cuenta los valores y creencias del paciente, la familia y la comunidad.

Y todo ello en el consultorio y en el domicilio; y mucho por teléfono, por correo-electrónico, conferencia virtual, o …¡en la acera, incluso!

El médico de cabecera trabaja en Atención Primaria, el nivel más próximo del Sistema Sanitario, el más accesible, donde se responde al 90% de los problemas de la población, donde hay un equipo que complementa al médico. Cuando la Atención Primaria es fuerte, el médico de cabecera es “filtro” para la atención de los especialistas. Así es, por ejemplo, en Canadá (Ontario), Dinamarca, Eslovenia, España, Holanda, Noruega, Nueva Zelanda y el Reino Unido. El “filtro” hace que los especialistas se enfrenten a casos difíciles de su especialidad, y por ello contribuye a mantener la “pureza de raza” de los especialistas.

Además, el “filtro” evita el “exceso” de atención de los especialistas,
necesario sólo en casos escogidos, en los que compensan los daños ciertos con beneficios probables.

Los especialistas deberían actuar de consultores, de forma que el médico
de cabecera decidiera al final, de acuerdo con el paciente (y su contexto). Con esa coordinación se “produce” más salud y se ahorra dinero (para el paciente y su familia, y para la población y la nación).

Tenga un médico de cabecera que coordine su atención, y que le ayude a
decidir cuándo necesita cuidados especializados, y de qué especialista. Con ello protegerá su salud y la de su familia (y su dinero).


Este texto se encuentra bajo licencia Creative Commons by-nc-sa 3.0, por lo tanto se puede distribuir y re-elaborar libremente a condición de citar a los autores, no utilizarlo para fines comerciales y mantener el producto subsiguiente bajo este mismo tipo de licencia (licencia completa).

1Llamamos médico de cabecera al médico general que atiende al paciente y a su familia en todos los casos y situaciones (en el consultorio y en el domicilio del paciente, desde la concepción a la muerte, y desde la
salud a la enfermedad) y que solicita el trabajo de consultor del médico especialista en situaciones episódicas que requieren tecnología o conocimientos específicos. El nombre de “médico de cabecera” alude a la
visita a domicilio, a estar junto a la “cabecera” de la cama del paciente; también alude a consejero muy cercano, de la familia. El médico general se transformó en “médico de familia” en los EEUU, en la
década del 60 del siglo XX, por el rechazo del Comité de Especialización a reconocer como una especialidad lo que se dedicaba a lo general. El nombre de médico de familia es el que se emplea oficialmente en España y otros países, como Brasil. Persiste el nombre oficial de médico general en el Reino Unido, Irlanda, Holanda, Noruega, Francia, Nueva Zelanda y otros países. En la Unión Europea (27 países, 500 millones de habitantes) para trabajar en el Servicios de Salud público se exige el título de especialista en Medicina General-de Familia (residencia de tres años, como mínimo),

Juan Gérvas


Si no ha leido todavia quien es Juan Gervas es porque no ha leido nunca este o alguno de mis otros blogs. Vive cerca de Madrid, es profesor de la escuela de Sanidad, ha sido profesor en la Universidad de John Hopkins ( una de las mas prestigiosas del mundo ), y estemos o no de acuerdo con sus dichos (supongo que el escribiría lo mismo ), su honestidad intelectual, su capacidad y el humanismo con el que ejerce y enseña, constituyen siempre un poco de aire fresco para quienes trabajamos en atención primaria. Si bien se presenta, en reportajes, cómo médico rural, esto es más una provocación a quienes asumen que la verdadera ciencia sólo se puede hacer en los hospitales, cuando el 90% de los problemas se pueden resolver fuera del mismo. Los hospitales, a decir de Julio Ceitlin (ciudadano del mundo que vive en Buenos Aires), son templos de enfermedad, y debemos reivindicar a la atención primaria, incluso hasta con investigación, tal cómo Amado Martin Zurro plantea: “hay que demostrar que existe vida inteligente fuera de los hospitales”. Cosa no siempre fácil, cuando a un centro de salud, más de uno lo llama “centro periférico” (si es centro no es periférico), y no tiene porque estar en los barrios pobres de las ciudades, también pueden estar en pleno centro de una ciudad, cómo varios hospitales de comunidad e incluso prepagas han demostrado en Buenos Aires, o en la misma Habana, y también, desmintiendo a Juan Gervas, en muchas grandes ciudades de Estados Unidos. Claro que si de médicos personales se trata, el más conocido siempre es el médico personal del presidente, del jeque o del rey, ellos si tienen médicos personales, porque se sabe muy bien que la acción no coordinada en la atención médica, conlleva más daños que beneficios. Y el resto ya lo contó Juan.

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Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trial

Age-standardised disability-adjusted life year...                          Image via WikipediaGriffin SJ, Borch-Johnsen K, Davies MJ, et al. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): a cluster-randomised trialLancet. 2011 Jun 24. (Original) PMID: 21705063

BACKGROUND: Intensive treatment of multiple cardiovascular risk factors can halve mortality among people with established type 2 diabetes. We investigated the effect of early multifactorial treatment after diagnosis by screening.
METHODS: In a pragmatic, cluster-randomised, parallel-group trial done in Denmark, the Netherlands, and the UK, 343 general practices were randomly assigned screening of registered patients aged 40-69 years without known diabetes followed by routine care of diabetes or screening followed by intensive treatment of multiple risk factors. The primary endpoint was first cardiovascular event, including cardiovascular mortality and morbidity, revascularisation, and non-traumatic amputation within 5 years. Patients and staff assessing outcomes were unaware of the practice`s study group assignment. Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00237549.
FINDINGS: Primary endpoint data were available for 3055 (99.9%) of 3057 screen-detected patients. The mean age was 60.3 (SD 6.9) years and the mean duration of follow-up was 5.3 (SD 1.6) years. Improvements in cardiovascular risk factors (HbA(1c) and cholesterol concentrations and blood pressure) were slightly but significantly better in the intensive treatment group. The incidence of first cardiovascular event was 7.2% (13.5 per 1000 person-years) in the intensive treatment group and 8.5% (15.9 per 1000 person-years) in the routine care group (hazard ratio 0.83, 95% CI 0.65-1.05), and of all-cause mortality 6.2% (11.6 per 1000 person-years) and 6.7% (12.5 per 1000 person-years; 0.91, 0.69-1.21), respectively.
INTERPRETATION: An intervention to promote early intensive management of patients with type 2 diabetes was associated with a small, non-significant reduction in the incidence of cardiovascular events and death.
FUNDING: National Health Service Denmark, Danish Council for Strategic Research, Danish Research Foundation for General Practice, Danish Centre for Evaluation and Health Technology Assessment, Danish National Board of Health, Danish Medical Research Council, Aarhus University Research Foundation, Wellcome Trust, UK Medical Research Council, UK NIHR Health Technology Assessment Programme, UK National Health Service R&D, UK National Institute for Health Research, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Novo Nordisk, Astra, Pfizer, GlaxoSmithKline, Servier, HemoCue, Merck.

Putting research into primary care practice

BMJ 2011; 343:d3922 doi: 10.1136/bmj.d3922 (Published 5 July 2011)

Cite this as: BMJ 2011; 343:d3922

  • Editorial

Putting research into primary care practice

  1. Frede Olesen, professor
1Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark
  1. fo@alm.au.dk
The European initiative is a good start, but excludes too many patients and crucial aspects of primary care
The European Medical Research Council and European Science Foundation recently published a strategic report in its series of “Current Forward Looks” entitled Implementation of Medical Research in Clinical Practice. 1 The collaboration has previously published two strategic reports on the ways forward for basic biological research and for investigator driven clinical trials. 1 By suggesting a strategy on the use of research in practice, it now intends to close the loop. The strategy holds much potential for improving the quality of clinical practice and clinically oriented health services research.
The report has three main strengths: firstly, it takes strategy and policy to the level of specific recommendations for improving the quality of clinical research; secondly, it presents a strong case for the implementation of good research; and, thirdly, it gives special attention to the particular problems encountered in general practice.
The report proposes that the quality of clinical research could be improved by closer national and European coordination of independent funding of larger projects, …

In Memorian: JH´s Dean for Barbara Starfield

Johns Hopkins Bloomberg School of Public HealthImage via WikipediaMessage from the Dean

Johns Hopkins Bloomberg School of Public Health

Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming-an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area.

Barbara came to Johns Hopkins in 1959 as a fellow in pediatrics at the School of Medicine. She joined our School in 1962 where she earned her MPH in epidemiology. As professor, she went on to lead the Division of Health Policy in the Department of Health Policy and Management from 1975 to 1994. After stepping down as Division head, Barbara remained an active member of the HPM faculty and was founding director of the Primary Care Policy Center. She was named Distinguished University Professor in 1994. Barbara was greatly admired as a teacher, mentor and colleague.

I am sure that I speak for all of us when I say that my deepest sympathies are with Tony Holtzman–Barbara’s husband, her four children, her eight grandchildren, as well her many friends and colleagues around the world.

We’ll provide information about funeral arrangements and a memorial service when they are available.

Michael J. Klag, MD, MPH


Johns Hopkins Bloomberg School of Public Health

Web links:






In Memorian: Barbara Starfield

Con profunda tristeza los médicos generales y de familia recibimos la noticia del fallecimiento de Barbara Starfield. Comprometida con la atención primaria, las palabras huelgan y copio aqui, para quienes no la conocieron, su pagina de profesora en John Hopkins, la misma Universidad donde nació el modelo flexneriano y que ella combatió. Tuve el honor de, si bien no conocerla personalmente, leerla en la lista de “Social Determinats of Health”, e intercambiar opiniones a través de e-mails. Hemos perdido a un simbolo de la Atención Primaria, pero su pensamiento seguirá vivo. Mi condolencia también a su amigo, quien me dió la noticia, Juan Gervas.

Barbara Starfield


Academic Degrees
Departmental Affiliation
Health Policy and Management
Affiliation Type:
Primary Care Policy Center
Population, Family and Reproductive Health
Affiliation Type:
Departmental Address
452 Hampton House
Contact Information
Personal Website
Research and Professional Experience
Determinants of health and equity in health; effectivenss and equity of health services; assessment of population health; co-morbidity and case mix; primary care and specialty care and their interrelationships; continuity (longitudinality) of care and its effects; comprehensiveness and coordination of care

Honors and Awards
David Luckman Memorial Award, State University of New York, Downstate Medical Center, 1958. The 1967 Award of The Enuresis Foundation for “significant contribution to knowledge and understanding of enuresis.” Research Scientist Development Award (K02 HS 46225) from the National Center for Health Services Research and Development, 1970-75. Member, Institute of Medicine, National Academy of Sciences. Elected 1977. The George Armstrong Award for Work in Advancing the Goals of Improved Patient Care, Teaching, and Research in Ambulatory Pediatrics. The Ambulatory Pediatric Association, May 1983. First Annual Research Award for Contributions to Research in Child Health. The Ambulatory Pediatric Association, May 1990. Residential Scholar, Bellagio Study Center, Rockefeller Foundation, June 9 – July 13, 1990. Special Recognition Award for the Secretary for Health and Human Services (Task Force to Develop Child Health Indicators, 1990), May 1991. First National Primary Care Achievement Award, Pew Charitable Trusts/Health Resources and Services Administration (DHHS), 1994. Distinguished Investigator Award, Association for Health Services Research, 1995. American Public Health Association‘s Martha May Eliot Award, 1995. AHSR (Association for Health Services Research) Distinguished Fellow, 1996. Maurice Wood Award for Lifetime Contribution to Primary Care Research, North American Primary Care Research Group (NAPCRG), 2000. Honorary Fellow, Royal College of General Practitioners (UK), 2000. Lifetime Achievement Award, Ambulatory Pediatric Association, 2002. Morehouse School of Medicine Excellence in Primary Care Award, 2002

Selected Publications
Gervas J, Starfield B, Heath I. Is clinical prevention better than cure? Lancet 2008; 372:1997-9. Starfield B. Refocusing the system. N Engl J Med 2008; 359(20): 2087, 2091. Lee TH, Bodenheimer T, Goroll AH, Starfield B, Treadway K. Perspective roundtable: redesigning primary care. N Engl J Med 2008; 359(20): e24. Starfield B. Commentary: Access, primary care, and the medical home: rights of passage. Med Care 2008; 46: 1015-16. Starfield B. The biggest bang for the buck: a conversation with Barbara Starfield, M.D., M.P.H. Interview by Sallie Rixey. Md Med 2008; 9(3): 11-3. Rawaf S; De Maeseneer J; Starfield B. From Alma-Ata to Almaty: a new start for primary health care. Lancet 2008; 372(9647): 1365-7. Starfield B. An evidence base for primary care. Managed Care 2008; 17(6): 33-26, 39. Starfield B, Hyde J, Gérvas J, Heath I. The concept of prevention: a good idea gone astray? J Epidemiol Community Health 2008; 62: 580-83. Alonso J, Urzola D, Serra-Sutton V, Tebe C, Starfield B, Riley AW, Rajmil L. Validity of the health profile-types of the Spanish Child Health and Illness Profile – Adolescent Edition (CHIP-AE). Value in Health 2008; 11: 440-9. Starfield B. Editorial: The importance of primary care in health systems. Hong Kong Practitioner 2008; 30: 1-2. Starfield B. Comment: Quality and outcomes framework: patient-centred. Lancet 2008; 372: 692-4. Starfield B. Commentary: Primary care in Canada: coming or going? Healthc Pap 2008; 8: 58-62; discussion 64-7. Starfield B. Social gradients and child health. In Heggenhougen HK, Quah SR (eds.). International Encyclopedia of Public Health, Vol 6, pp. 87-101. San Diego, CA: Academic Press, 2008. Gervas J, Starfield B, Violan C, Minue S. GPs with special interests: unanswered questions. Br J Gen Pract 2007; 57: 912-7. Starfield B, Fryer GE Jr. The primary care workforce: ethical and policy implications. Ann Fam Med 2007; 5: 486-91. Starfield B, Birn A-E. Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health. J Epidemiol Community Health 2007; 61: 1038-41. Starfield B. Global health, equity, and primary care. J Am Board Fam Med 2007; 20(6): 511-3. Gérvas J, Starfield B, Minué S, Violan C, Seminario de Innovacion en Atencion Primaria 2007. [Some Causes (and Solutions) of the Loss of Prestige of General Practitioners/Family Doctors. Against the Discrediting of Heroes.]. Aten Primaria 2007; 39(11): 615-8. Beasley JW, Starfield B, vanWeel C, Rosser WW, Haq CL. Global health and primary care research. J Am Board Fam Med 2007; 20(6):518-26. Pueyo M-J, Serra-Sutton V, Alonso J, Starfield B, Rajmil L. Self-reported social class in adolescents: validity and relationship with gradients in self-reported health. BMC Health Services Research 2007; 7:151. Pasarin MI, Berra S, Rajmil L, Solans M, Borrell C, Starfield B. [An instrument to evaluate primary health care from the population perspective]. Aten Primaria 2007; 39 (8): 395-401. Forrest CB, Shadmi E, Nutting PA, Starfield B. Specialty referral completion among primary care patients: results from the ASPN Referral Study. Ann Fam Med 2007; 5: 361-7. Starfield B, Horder J. Interpersonal continuity: old and new perspectives. Br J Gen Pract 2007; 57 (540): 527-9. Starfield B. Pathways of influence on equity in health. Soc Sci Med 2007; 64 (7): 1355-62. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv 2007; 37(1): 111-26. Starfield B, Gervas J. Family medicine should encourage its clinicians to specialize: negative position. Chapter 10 in Buetow SA and Kenealy TW. Ideological Debates in Family Medicine, pp. 107-119. New York, NY: Nova Science Publishers, 2007. Starfield B, Shi L. Commentary: Primary care and health outcomes: a health services research challenge. Health Serv Res 2007; 42(6 Pt 1): 2252-6. Valderas JM, Starfield B, Salisbury C. Definitions of chronic health conditions in childhood. JAMA 2007; 298: 1636. Valderas JM, Starfield B, Roland M. Multimorbidity’s many challenges: A research priority in the UK. BMJ 2007; 334(7604): 1128. Starfield B, Shi L. Commentary: The impact of primary care and what states can do. North Carolina Medical Journal 2007; 68: 204-7. Starfield B. Editorial: Co-morbidity and its challenges for quality of primary care. Rev Port Clin Geral 2007; 23:179-80. Starfield B. Pathways of influence on equity in health: A rejoinder to Braveman and Wilkinson. Soc Sci Med 2007; 64(7): 1371-2.