Variation in the Ecology of Medical Care

By a commendable use of the 1996 MEPS data, Fryer et al succeeded in establishing the US ecology of health care in the nineties.1 Now, however, an even more difficult task lies ahead: ordering the MEPS data into episodes of illness and episodes of care, and to apply the epidemiological standards of international family practice.

When working with the then available 1996 MEPS data (during a scholarship at AHCPR, autumn 1999), Henk Lamberts and I found that they did not compare well with (Dutch, Japanese and Polish) family practice data collected with the International Classification of Primary Care (ICPC).2 The ICD-9-CM coding was a major barrier, and we were not able to assess which episodes of illness reported by the participants resulted in which episodes of care, how they developed over time, and what the contribution of the family doctor was.

Although it was promising that the database contained 3.6 episodes of illness and 2.1 episodes of care per patient per year, the distribution over the diagnostic categories looked rather ‘unusual’: important diseases such as ischemic heart disease, stroke, COPD, cardiac insufficiency, and, to a lesser extent, depression and anxiety appeared to be substantially underrepresented in comparison with morbidity data from other countries. Also, the substantial proportion of women using oral contraception could hardly be identified in the MEPS data.

In fact, after a grueling recoding of the ICD-9-CM codes into ICPC- codes, the good old NAMCS data did hold up much better in our comparative study, and at least do support US family doctors in the claim that they can play an effective primary care role.3,4 Fryer et al are to be congratulated with their work; and as a reward, American family practice should offer them the data they would deserve to have: episode oriented data routinely collected by US family doctors who are equipped with an electronic health record that is based on patients’ problems over time rather than on utilization.

References 1. Fryer GE, Green LA, Dovey SM, Yawn BP, Philips RL, Lanier D. Variations in the ecology of medical care. Ann Fam Med 2003;1:81-9. 1. Lamberts H, Okkes I. International comparison of morbidity data. An episode oriented study with MEPS data. Report of a study visit to the AHCPR Center for Primary Care Research, October-November 1999. Amsterdam: University of Amsterdam Department of General/Family Practice, 1999. 2. Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H. The role of Family Practice in different health care systems. A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States. J Fam Pract 2002; 51: 72-3. 3. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA,eds. Primary Care. America’s Health in a new Era. Washington, DC: National Academy Press, 1996.

Competing interests:   None declared