Comparative effectiveness research includes cohort studies and registries of interventions. When investigators design such studies, how important is it to follow patients from the day they initiated treatment with the study interventions? Our article considers this question and related issues to start a dialogue on the value of the incident user design in comparative effectiveness research. By incident user design, we mean a study that sets the cohort's inception date according to patients' new use of an intervention. In contrast, most epidemiologic studies enroll patients who were currently or recently using an intervention when follow-up began. We take the incident user design as a reasonable default strategy because it reduces biases that can impact non-randomized studies, especially when investigators use healthcare databases. We review case studies where investigators have explored the consequences of designing a cohort study by restricting to incident users, but most of the discussion has been informed by expert opinion, not by systematic evidence.

Nonwhite physicians are more likely to care for minority, medically indigent, and sicker patients. Caring for less affluent and sicker patients may financially penalize nonwhite physicians and make them particularly vulnerable to capitation arrangements.

Using data from the 1987 National Medical Expenditure Survey, characteristics of ambulatory service utilization for adolescents aged 11 through 17 were examined. Access to health care was further explored by identifying adolescents at risk of not receiving an ambulatory service in the event of symptomatology. Approximately two-thirds of an estimated 25 million adolescents experienced an outpatient visit. African American race, Hispanic ethnicity, middle income, and lack of insurance and a usual source of care placed adolescents at risk for not receiving an ambulatory service. Sixteen million adolescents experienced symptomatology, but only one-third saw a physician. Those lacking a usual source of care were at greater odds of not receiving care. For symptom-based care, inequities were related more to lack of usual source of care rather than socioeconomic characteristics. Health care reform efforts may benefit from ensuring that adolescents have an identified usual source of care to ensure equity of access to care.

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