The influence of regional health care structures on delay in diagnosis of rare diseases: the case of Marfan Syndrome

Late diagnosis of Marfan syndrome is associated with unplanned aortic surgery and cardiovascular death

BACKGROUND

Marfan syndrome (MFS) guidelines recommend optimal pharmacologic therapy (OPT) and replacement of the ascending aorta (RAA) at 5.0 cm in diameter to prevent acute type A aortic dissection (ATAAD) and death. The effect of early MFS diagnosis and initiation of therapy on outcomes is not known. Therefore, we sought to evaluate the effect of age at MFS diagnosis and therapy initiation on delayed RAA and death.

METHODS

This retrospective observational cohort study with long-term follow-up included consecutive patients with MFS, pathogenic FBN1 variant, and regular visits to a European Reference Network Center. We considered MFS diagnosis at age ≥21 years late and OPT initiation at age <21 years early. Outcomes were delayed RAA with aneurysm diameter >5.0 cm or ATAAD and death from all causes. We used landmark design starting at age 21 years to determine associations with outcomes.

RESULTS

The study group consisted of 288 patients (45.1% male), including 169 patients with late diagnosis of MFS (58.7%) and 63 with early OPT (21.9%). During mean follow-up of 25 ± 14.7 years, 78 patients had delayed RAA, with 42 operations for ATAAD and 36 for aneurysms ≥5.0 cm. There were 33 deaths, including 11 deaths late after ATAAD. All deaths were cardiovascular. Late diagnosis, but not early OPT, showed univariate association with delayed RAA (P < .001) and death (P = .025). Multivariate Cox regression analysis confirmed late diagnosis as predictor of delayed RAA (hazard ratio, 8.01; 95% confidence interval, 2.52-25.45; P < .001) and death (hazard ratio, 4.68; 95% confidence interval, 1.17-18.80; P = .029).

CONCLUSIONS

Late diagnosis of MFS is associated with delayed surgery and death.

Bone disease and oromaxillofacial disorders: a cross- sectional study in a Tanzanian pediatric population

BACKGROUND

Certain bone diseases of congenital origin are associated with dental alterations and with oromaxillofacial (OMF) disorders. The objective of this study was to evaluate and compare the OMF alterations presented by patients affected by bone pathology with respect to a healthy population from the same geographical environment.

MATERIAL & METHODS

A cross-sectional study was carried out at Mount Meru Regional Referral Hospital and Kaloleni secondary school in Arusha, Tanzania. The patients with bone pathologies (n = 60) were consecutively recruited from the hospital, while the controls (n = 581) comprised a population of healthy students from the school, which was located in the same neighbourhood as the hospital. In the case group, the different bone pathologies were divided into two subgroups: (i) disorders in cellular metabolism (DCM); and (ii) disorders of bone growth/deformity (DGD). Musculoskeletal and oral clinical examinations were performed in both groups.

RESULTS

The case group presented significantly higher values of moderate and severe inflammation on the Löe & Silness Gingival Index (GI 2: 65%, GI 3: 25%) than the control group (p < 0.001), where mild inflammation predominated (GI 1: 88%). The case group also had higher scores for decayed, missing and filled teeth. Dental fluorosis was reported in 75.2% of controls and in only 26.6% of cases, the differences being clearly significant (p < 0.001). Significant differences for fluorosis were also reported between the two subgroups (p < 0.001), with a higher incidence for the DCM subgroup (43.8%). Twenty-two patients (36.7%) in the case group displayed clinical absence of teeth: the rate was significantly higher in the DGD subgroup (n = 15, 50%) than in the DCM subgroup (n = 8, 25%) (p = 0.045). In relation to the type of dental occlusion, the group with bone pathology presented a significant predominance of Angle class II - III malocclusions (p < 0.001). Craniofacial abnormalities were more frequent in the DGD subgroup, although the difference was not significant. The spine was normal in 41 patients (68.3%) and the differences between subgroups were not significant. Pathological fractures were significantly more frequent in the DGD subgroup (50% vs. 6.3%; p < 0.001). Assessing whether there was a relationship between malocclusion and skeletal deformities (spine and upper limb) in the case group, subjects with upper limb deformity (n = 16) presented significant differences for inverted overjet (p = 0.031).

CONCLUSION

Patients with bone disease had worse oral health and more severe dental malocclusion than controls. The results presented here may help to raise awareness among orthopedic and pediatric professionals of abnormalities related to OMF conditions in childhood.

Diagnostic Process in Rare Diseases: Determinants Associated with Diagnostic Delay

Many people living with rare disease (RD) report a difficult diagnostic process from the symptom onset until they obtain the definitive diagnosis. The aim of this study was thus to ascertain the diagnostic process in RDs, and explore the determinants related with having to wait for more than one year in this process (defined as “diagnostic delay”). We conducted a case–control study, using a purpose-designed form from the Spanish Rare Diseases Patient Registry for data-collection purposes. A descriptive analysis was performed and multivariate backward logistic regression models fitted. Based on data on 1216 patients living with RDs, we identified a series of determinants associated with experiencing diagnostic delay. These included: having to travel to see a specialist other than that usually consulted in the patient’s home province (OR 2.1; 95%CI 1.6–2.9); visiting more than 10 specialists (OR 2.6; 95%CI 1.7–4.0); being diagnosed in a region other than that of the patient’s residence at the date of symptom onset (OR 2.3; 95%CI 1.5–3.6); suffering from a RD of the nervous system (OR 1.4; 95%CI 1.0–1.8). In terms of time taken to see a specialist, waiting more than 6 months to be referred from the first medical visit was the period of time which most contributed to diagnostic delay (PAR 30.2%). In conclusion, this is the first paper to use a collaborative study based on a nationwide registry to address the diagnostic process of patients living with RDs. While the evidence shows that the diagnostic process experienced by these persons is complex, more studies are needed to determine the implications that this has for their lives and those of their families at a social, educational, occupational, psychological, and financial level.

Association of time to diagnosis with socioeconomic position and geographical accessibility to healthcare among symptomatic COVID-19 patients: A retrospective study in Hong Kong

Early diagnosis is important to control COVID-19 outbreaks. This study aimed to assess how individual and area socioeconomic position and geographical accessibility to healthcare services were associated with the time to diagnosis among symptomatic COVID-19 patients in Hong Kong. Multivariable generalized linear regression was used to estimate the associations while adjusting for sociodemographic characteristics and case classification. This study found living in public rental housing and living in an area with low education were associated with longer time to diagnosis in the first wave of infections. Specifically, the risk of delayed diagnosis for public rental housing residents was mitigated by the higher density of public clinics/hospitals but was slightly increased by the higher density of private medical practitioners nearby. No such relations were found in the second wave of infections when the surveillance measures were enhanced. Given the grave impact of pandemics around the world, our findings call on taking inequalities into account when public health policies are being devised.

Multidisciplinary aortopathy clinics: A systematic scoping review of the literature and evaluation of patient experiences from a newly started clinic in Norway

BACKGROUND

International guidelines recommend hereditary thoracic aortic diseases (HTADs) to be managed in multidisciplinary aorta clinics.

AIM

To study HTAD patient's experiences with a aortopathy clinic in Norway and to review the literature on aortopathy clinics.

METHODS

(a) A systematic scoping review of research on multidisciplinary clinics for HTADs. (b) A cross-sectional postal questionnaire study to investigate patient experiences with the health-services. Fifty consecutive patients from the aortopathy clinic and 50 controls in usual care were invited to participate.

RESULTS

The review identified eight publications on aortopathy clinics. Although the papers were not judged for quality, these showed promising results from such clinics in terms of diagnostics and increased adherence to guideline-directed therapy. The survey constituted thirty-seven (74%) patients and 22 (44%) controls who responded to postal questionnaires. Both groups reported delays in diagnostics and follow-up appointments prior to the start of the clinic. Patients indicated high satisfaction with the aortopathy clinic, whereas controls reported poor coordination of medical follow-up. Individuals in both groups struggled with disease self-management.

CONCLUSION

Norwegian patient experiences found the aortopathy clinic beneficial. According to studies included in the review, disease management in aortopathy clinics may improve patient satisfaction, diagnostics and follow-up. Effect studies may further document the benefits of clinic organization, treatment, cost-efficiency and patient experiences.

Oral Health-Related Quality of Life in People with Rare Hereditary Connective Tissue Disorders: Marfan Syndrome

Background: The aim of this study was to analyze data on oral health-related quality of life (OHRQoL) in people with Marfan syndrome and to obtain information on the diagnosis period, orthodontic treatment, and oral symptoms. Methods: A questionnaire was developed consisting of open questions and the standardized German version of the OHIP-14 (Oral Health Impact Profile) questionnaire for the evaluation of OHRQoL. The age of diagnosis, time period from the first signs of the disease to diagnosis, and OHIP-values were compared between male and female participants. Additionally, the OHIP-values between participants who were orthodontically treated and those who were not treated were assessed. The statistical analysis was performed using the Mann–Whitney test with a significance level at p = 0.05. Results: A total of 51 questionnaires were evaluated, which included 34 female and 17 male participants. Overall, 84% of respondents reported oral symptoms. Male respondents tended to diagnose the disease earlier (p = 0.00), with a smaller period between the first symptom and the diagnosis (p = 0.04). The OHIP-14 score was gender-neutral at 13.65 ± 13.53 points. Conclusion: In Marfan syndrome, many years (12.01 ± 11.61) elapse between the onset of first symptoms and correct diagnosis of the disease. People with Marfan syndrome have a worse OHRQoL than do the general population.

Routinely collected health data to study inherited heart disease: a systematic review (2000-2016)

Objective

Our understanding of inherited heart disease is predominantly based on retrospective specialised clinic cohorts, which have inherent selection bias. Population-based routinely collected data can provide insight into unbiased, large-scale patterns of treatment and care but may be limited by the granularity of clinical information available. We sought to synthesise the global literature to determine whether we can identify patients with inherited heart diseases using routinely collected health data.

Methods

Medline, Embase, CINAHL, PreMEDLINE and Google Scholar citation databases were searched for relevant articles published between 1 January 2000 and 31 October 2016.

Results

A total of 5641 titles/abstracts were screened and 46 full-text articles were retrieved. Twelve peer-reviewed, English-language manuscripts met our inclusion criteria. Studies predominantly focused on Marfan syndrome (41%) or hypertrophic cardiomyopathy (29%). All studies used International Classification of Disease diagnosis codes to define inherited heart disease populations; three studies also used procedure codes. Nine of the 17 definitions for inherited heart disease were repeated across studies.

Conclusions

Inherited heart disease populations can be identified using routinely collected health data, though challenges relate to existing diagnosis codes. This is an underutilised resource with the potential to inform patterns of care, patient outcomes and overall disease burden.

The health and life path of rare disease patients: results of the 2015 French barometer

Purpose

A barometer has been set up to provide better knowledge about the daily situation of French rare disease (RD) patients, their families and relatives, in order to contribute to the elaboration of improvement measures. This report focuses on the care and life path of RD patients.

Patients and methods

A preliminary survey was carried out with three patients, five parents and three RD experts to identify the main hurdles and disruptions in the life path of RD patients. It was used to design a larger survey comprising 60 questions as well as open fields allowing free expression. Respondents (448) comprised patients, parents of RD children and close relatives of patients. The Percentage of Maximum Deviation, Yates’ correction for continuity and Fisher’s test were employed to compare the responses between groups.

Results

Large disparities in the delays to obtain a diagnosis were identified (<1 year to >20 years), and longer delays were associated with negative perception of care conditions. While good interactions with education teams were reported (59% of respondents), the professional situation of both patients and parents was strongly and negatively impacted by the disease (51% did not work or stopped working). Three hundred respondents expressed various needs and psychological and personal issues were reported by 62% and 75% of respondents, respectively. Interestingly, the medical care path and daily life of RD patients were positively impacted by the follow-up in a specialized consultation, as reflected by changes in scores measured by our barometer (Fisher’s test, p<0.05).

Conclusion

Some of the main hurdles and sources of disruption in the life path of RD patients were identified, as well as some positive outcomes. These data could serve not only as a background for further studies, but also to better adapt the support to real needs and to improve the synergies between the many people involved in the life path of RD patients.

The structure of the pharmaceutical market in Iran using concentration indices

BACKGROUND AND OBJECTIVE

The efficiency and function of the pharmaceutical sector, as a vital portion of the health system, have a significant effect on intermediate and final indices of health. In this research, the structure of the pharmaceutical market in Iran was examined through the calculation of concentration indices in 2011.

METHODS

In this cross-sectional study, the needed data was gathered from the Food and Drug Administration in the year 2011. Data were analyzed using SPSS software version 20 and Microsoft Office Excel software. Finally, two common measures of market concentration, the Concentration Ratio and the Herfindahl-Hirschman Index, were calculated.

RESULTS

The largest and the smallest shares of the industry were 5.57% and 0.01%, respectively. The average industry share was 1.09%. The share range was calculated to be 5.56%. The Herfindahl-Hirschman Index was 248.5, which indicates a very low concentration of the pharmaceutical market in Iran. Also, based on the Concentration Ratio of 4 companies (18.39%), the concentration of the pharmaceutical market has been too low.

CONCLUSION

The pharmaceutical market in Iran has a very low concentration and it does not have an exclusive mode in terms of market structure. Therefore, it can be attributed to the competitive model. The policy makers in this area can use this characteristic as a leverage to improve efficiency, fairness, revenue and health indices.

Economic and care considerations of Marfan syndrome

INTRODUCTION

Marfan syndrome is a rare multisystem disease of the connective tissue, which affects multiple organ systems. advances in healthcare have doubled the life-expectancy of patients over the past three decades. to date, there is no comprehensive review that consolidates economic considerations and care for marfan patients. Areas covered: Present research suggests that there may be a link between treatment pattern, disease progression and economic costs of Marfan syndrome. It indicates that an early detection of the disease and preventive interventions achieve a dual aim. From a patient perspective, it may reduce the amount of emergency surgery or intervention, and inpatient stays. In addition, it slows disease progression, lowers lifestyle restrictions, reduces psychological stress, and improves health-related quality of life. Expert commentary: Early detection and preventive measures are likely to achieve a dual aim by simultaneously containing costs and reducing the number and length of inpatient stays.

Regional differences in health care of patients with inflammatory bowel disease in Germany

BACKGROUND

The regional availability of specialized physicians is an important aspect in healthcare of patients with IBD. The association between physician density and healthcare is not yet clear. Most studies did not consider district type, which reflects population density. Our research question was, "Do specialist density and district type influence the healthcare of IBD patients in Germany?"

METHODS

We combined a claims dataset from a German health insurance fund with population and physician data. Four main aspects were investigated: regular specialist visits, drug therapies, surveillance colonoscopy, and IBD-related hospitalizations. Various regression analyses were performed.

RESULTS

The study cohort was comprised of 21,771 individuals, including 9282 patients with Crohn disease and 12,489 patients with ulcerative colitis. Patients who were living in districts with higher specialist densities were more likely to attend specialist visits on a regular basis. No difference in the frequencies of TNF-alpha inhibitor therapies was found. However, individuals from urban areas were more likely to receive a permanent immunosuppressive therapy with continuous specialist support.

CONCLUSIONS

The results revealed that some aspects had positive effects on the probability of implementing healthcare in accordance with pathways and guidelines. No clear evidence of a general healthcare undersupply in rural areas was found.

[Genetics and prevention of genetic aortic syndromes (GAS) and of the Marfan syndrome]

BACKGROUND

Genetic aortic syndromes are autosomal-dominantly heritable aneurysms of the thoracic aorta, which carry a high risk of aortic rupture or acute thoracic aortic dissection at young age.

OBJECTIVES

We introduce the reader to the principles of genetic diagnostics and the medical and surgical prevention of thoracic aortic dissection in patients with genetic aortic syndromes.

METHODS

A cardiologist, a health economist, a patient representative, a heart surgeon, and a molecular geneticist teamed up to elucidate their perspective on major aspects of genetics and prevention of genetic aortic syndromes.

RESULTS

Genetic aortic syndromes reflect a broad spectrum of diverse disease entities comprising the Marfan syndrome, the Loeys-Dietz syndrome or the vascular Ehlers-Danlos syndrome. The diagnosis of each respective disease entity requires combined assessment of phenotype and genotype information. A medical prevention of aortic complications such as dissection is mandatory although a curative therapy currently appears unlikely in humans. The single most important measure against acute aortic dissection is the preventive replacement of the aortic root, where valve preserving techniques appear preferable. Comprehensive prophylaxis including molecular diagnostics seem reasonable also from an economic point of view.

DISCUSSION

Optimal prevention requires individualization of concepts, which entail a detailed diagnostic characterization of each specific genetic aortic syndrome including characterization of the genotype.

Perspectives on the revised Ghent criteria for the diagnosis of Marfan syndrome

Three international nosologies have been proposed for the diagnosis of Marfan syndrome (MFS): the Berlin nosology in 1988; the Ghent nosology in 1996 (Ghent-1); and the revised Ghent nosology in 2010 (Ghent-2). We reviewed the literature and discussed the challenges and concepts of diagnosing MFS in adults. Ghent-1 proposed more stringent clinical criteria, which led to the confirmation of MFS in only 32%–53% of patients formerly diagnosed with MFS according to the Berlin nosology. Conversely, both the Ghent-1 and Ghent-2 nosologies diagnosed MFS, and both yielded similar frequencies of MFS in persons with a causative FBN1 mutation (90% for Ghent-1 versus 92% for Ghent-2) and in persons not having a causative FBN1 mutation (15% versus 13%). Quality criteria for diagnostic methods include objectivity, reliability, and validity. However, the nosology-based diagnosis of MFS lacks a diagnostic reference standard and, hence, quality criteria such as sensitivity, specificity, or accuracy cannot be assessed. Medical utility of diagnosis implies congruency with the historical criteria of MFS, as well as with information about the etiology, pathogenesis, diagnostic triggers, prognostic triggers, and potential complications of MFS. In addition, social and psychological utilities of diagnostic criteria include acceptance by patients, patient organizations, clinicians and scientists, practicability, costs, and the reduction of anxiety. Since the utility of a diagnosis or exclusion of MFS is context-dependent, prioritization of utilities is a strategic decision in the process of nosology development. Screening tests for MFS should be used to identify persons with MFS. To confirm the diagnosis of MFS, Ghent-1 and Ghent-2 perform similarly, but Ghent-2 is easier to use. To maximize the utility of the diagnostic criteria of MFS, a fair and transparent process of nosology development is essential.

The economic impact of Marfan syndrome: a non-experimental, retrospective, population-based matched cohort study

Background

Marfan syndrome is a rare disease of the connective tissues, affecting multiple organ systems. Elevated morbidity and mortality in these patients raises the issue of costs for sickness funds and society. To date, there has been no study analysing the costs of Marfan syndrome from a sickness fund and societal perspective.

Objective

To estimate excess health resource utilisation, direct (non-)medical and indirect costs attributable to Marfan syndrome from a healthcare payer and a societal perspective in Germany in 2008.

Methods

A retrospective matched cohort study design is applied, using claims data. For isolating the causal effect of Marfan syndrome on excess costs, a genetic matching algorithm was used to reduce differences in observable characteristics between Marfan syndrome patients and the control group. 892 patients diagnosed with Marfan syndrome (ICD-10 Q87.4) were matched from a pool of 26,645 control individuals. After matching, we compared health resource utilisation and costs.

Results

From the sickness fund perspective, an average Marfan syndrome patient generates excess annual costs of €2496 compared with a control individual. From the societal perspective, excess annual costs amount to €15,728. For the sickness fund, the strongest cost drivers are inpatient treatment and care by non-physicians. From the sickness fund perspective, the third (25–41 years) and first (0–16 years) age quartiles reveal the greatest surplus in total costs. Marfan syndrome patients have 39% more physician contacts, a 153% longer average length of hospital stay, 119% more inpatient stays, 33% more prescriptions, 236% more medical imaging and 20% higher average prescription costs than control individuals. Depending on the prevalence, the economic impact from the sickness fund perspective ranges between €24.0 million and €61.4 million, whereas the societal economic impact extends from €151.3 million to €386.9 million.

Conclusions

Relative to its low frequency, Marfan syndrome requires high healthcare expenditure. Not only the high costs of Marfan syndrome but also its burden on patients’ lives call for more awareness from policy-makers, physicians and clinical researchers. Consequently, the diagnosis and treatment of Marfan syndrome should begin as soon as possible in order to prevent disease complications, early mortality and substantial healthcare expenditure.

A population-based registry as a source of health indicators for rare diseases: the ten-year experience of the Veneto Region's rare diseases registry

Background

Although rare diseases have become a major public health issue, there is a paucity of population-based data on rare diseases. The aim of this epidemiological study was to provide descriptive figures referring to a sizable group of unrelated rare diseases.

Methods

Data from the rare diseases registry established in the Veneto Region of north-east Italy (population 4,900,000), referring to the years from 2002 to 2012, were analyzed. The registry is based on a web-based system accessed by different users. Cases are enrolled by two different sources: clinicians working at Centers of expertise officially designated to diagnose and care patients with rare diseases and health professionals working in the local health districts. Deaths of patients are monitored by Death Registry.

Results

So far, 19,547 patients with rare diseases have been registered, and 23% of them are pediatric cases. The overall raw prevalence of the rare diseases monitored in the population under study is 33.09 per 10,000 inhabitants (95% CI 32.56-33.62), whilst the overall incidence is 3.85 per 10,000 inhabitants (95% CI 3.67-4.03). The most commonly-recorded diagnoses belong to the following nosological groups: congenital malformations (Prevalence: 5.45/10,000), hematological diseases (4.83/10,000), ocular disorders (4.47/10,000), diseases of the nervous system (3.51/10,000), and metabolic disorders (2,95/10,000). Most of the deaths in the study population occur among pediatric patients with congenital malformations, and among adult cases with neurological diseases. Rare diseases of the central nervous system carry the highest fatality rate (71.36/1,000). Rare diseases explain 4.2% of general population Years of Life Lost (YLLs), comparing to 1.2% attributable to infectious diseases and 2.6% to diabetes mellitus.

Conclusions

Our estimates of the burden of rare diseases at population level confirm that these conditions are a relevant public health issue. Our snapshot of their epidemiology is important for public health planning purposes, going to show that population-based registries are useful tools for generating health indicators relating to a considerable number of rare diseases, rather than to specific conditions.

Spatial clusters of autism births and diagnoses point to contextual drivers of increased prevalence

Autism prevalence has risen dramatically over the past two decades in California. Although often suggested to have been crucial to the rise of autism, environmental and social contextual drivers of diagnosis have not been extensively examined. Identifying the spatial patterning of autism cases at birth and at diagnosis can help clarify which contextual drivers are affecting autism's rising prevalence. Children with autism not co-morbid with mental retardation served by the California Department of Developmental Services during the period 1992-2005 were matched to California's Birth Master Files. We search for spatial clusters of autism at time of birth and at time of diagnosis using a spatial scan approach that controls for key individual-level risk factors. We then test whether indicators of neighborhood-level diagnostic resources are associated with the diagnostic clusters and assess the extent of clustering by autism symptom severity through a multivariate scan. Finally, we test whether children who move into neighborhoods with higher levels of resources are more likely to receive an autism diagnosis relative to those who do not move with regard to resources. Significant birth and diagnostic clusters of autism are observed independent of key individual-level risk factors. While the clusters overlap, there is a strong positive association between the diagnostic clusters and neighborhood-level diagnostic resources. In addition, children with autism who are higher functioning are more likely to be diagnosed within a cluster than children with autism who are lower functioning. Most importantly, children who move into a neighborhood with more diagnostic resources than their previous residence are more likely to subsequently receive an autism diagnosis than children whose neighborhood resources do not change. We identify birth and diagnostic clusters of autism in California that are independent of individual-level autism risk factors. Our findings implicate a causal relationship between neighborhood-level diagnostic resources and spatial patterns of autism incidence but do not rule out the possibility that environmental toxicants have also contributed to autism risk.

General practitioner (family physician) workforce in Australia: comparing geographic data from surveys, a mailing list and medicare

Background

Good quality spatial data on Family Physicians or General Practitioners (GPs) are key to accurately measuring geographic access to primary health care. The validity of computed associations between health outcomes and measures of GP access such as GP density is contingent on geographical data quality. This is especially true in rural and remote areas, where GPs are often small in number and geographically dispersed. However, there has been limited effort in assessing the quality of nationally comprehensive, geographically explicit, GP datasets in Australia or elsewhere.

Our objective is to assess the extent of association or agreement between different spatially explicit nationwide GP workforce datasets in Australia. This is important since disagreement would imply differential relationships with primary healthcare relevant outcomes with different datasets. We also seek to enumerate these associations across categories of rurality or remoteness.

Method

We compute correlations of GP headcounts and workload contributions between four different datasets at two different geographical scales, across varying levels of rurality and remoteness.

Results

The datasets are in general agreement with each other at two different scales. Small numbers of absolute headcounts, with relatively larger fractions of locum GPs in rural areas cause unstable statistical estimates and divergences between datasets.

Conclusion

In the Australian context, many of the available geographic GP workforce datasets may be used for evaluating valid associations with health outcomes. However, caution must be exercised in interpreting associations between GP headcounts or workloads and outcomes in rural and remote areas. The methods used in these analyses may be replicated in other locales with multiple GP or physician datasets.

Analyzing regional variation in health care utilization using (rich) household microdata

This paper exploits rich SOEP microdata to analyze state-level variation in health care utilization in Germany. Unlike most studies in the field of the Small Area Variation (SAV) literature, our approach allows us to net out a large array of individual-level and state-level factors that may contribute to the geographic variation in health care utilization. The raw data suggest that state-level hospitalization rates vary from 65 to 165 percent of the national mean. Ambulatory doctor visits range from 90 to 120 percent of the national mean. Interestingly, in the former GDR states, doctor visit rates are significantly below the national mean, while hospitalization rates lie above the national mean. The significant state-level differences vanish once we control for individual-level socio-economic characteristics, the respondents' health status, their health behavior as well as supply-side state-level factors.

[Diagnostic delay of rare diseases in Europe and in Hungary]

The long diagnostic delay is a characteristic problem of rare disease patients.

AIMS

Diagnostic delay was studied in 14 countries by EurordisCare2 involving patient organizations.

METHODS

252 Hungarian patients (cystic fibrosis; Duchenne muscular dystrophy; tuberous sclerosis, retinitis pigmentosa, and Williams' syndrome) completed the questionnaires.

RESULTS

The median delay was longer in Hungary than in Europe (cystic fibrosis: 227 vs. 45 days; Duchenne muscular dystrophy: 467 vs. 360 days; tuberous sclerosis: 155 vs. 120 days). Patients' experience was similar in Hungary and in Europe. The proportion of misdiagnosis was 30.8% in Hungary (Europe: 41%), 34.8% of patients got diagnosis outside of living place region (EU: 26%) and 19.9% of them found the personal expenses too high (EU: 10%). Delivery of the diagnosis was unnecessary according to 27.4% of Hungarian patients (EU: 35%).

CONCLUSIONS

The qualitative survey demonstrated that the problems with the diagnosis of rare diseases are widespread, the identified areas require interventions, and it confirmed the importance of centralized care.