Insights and Concerns of Patients and GPs Regarding Introduction of Universal Health Insurance in Ireland

The implementation of a universal health insurance (UHI) model is a key political policy in Ireland. The objective here was to determine the understanding of general practitioners (GPs) and patients regarding UHI, its implementation and impact on both sets of stakeholders. Postal questionnaire to GPs, and opportunistic survey sampling of patients in two different GP practices were carried out. Response rates were 92.5% (patients) and 78% (GPs). 79.4% of patients (n = 418) and 96.7% of GPs (n = 149) have a 'poor' understanding of how UHI will be implemented. 89% (n = 493) of patients and 98.7% (n = 153) of GPs feel government communication about UHI has been 'poor'. 98.1% of GPs (n = 152) and 77.3% of patients (n = 383) are not confident that 'UHI will be ready for implementation by 2015'. Neither stakeholder group is confident in the government's ability to deliver UHI within the given timeframe. There is a lack of knowledge and consultation on proposals for its implementation.

Chordoma of the lumbar spine - a potential diagnosis not to be forgotten

Chordoma is a rare, malignant neoplasm thought to develop from the notochord. It most commonly occurs in the base of the cranium or the sacro-coccygeal region but around 15-20% affect the vertebral body. Extra-lesional resection with or without adjuvant radiotherapy is generally accepted as the mainstay of treatment for this slow-growing tumour. We present a case whereby a patient with a solitary L3 vertebral body lesion causing caudal compression was treated with spinal decompression and posterior stabilisation. Pre-operative biopsy was not performed as the lesion was presumed to be a metastatic deposit from a co-existing renal mass. Intra-operative biopsy, however, identified the tumour to be chordoma of the L3 vertebral body which would have been more appropriately treated with ‘en-bloc’ excision. This case highlights the importance of pre-operative tissue diagnosis, and that, although rare (0.8 per 100,000), chordoma should always be considered.

Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys

BACKGROUND

Screening to detect cancer early, an increasingly important cancer control activity, cannot be effective unless it is widely used.

METHODS

Use of Pap smears, mammography, fecal occult blood tests (FOBTs), sigmoidoscopy, and digital rectal examination (DRE) was evaluated in the 1987, 1992, and 1998 National Health Interview Surveys. Levels and trends in screening use were examined by sex, age, and racial/ethnic group. The effects of income, educational level, and health care coverage were examined within age groups. Logistic regression analyses of 1998 data were used to develop a parsimonious, policy-relevant model.

RESULTS

Use of all screening modalities increased over the period examined; for mammography and DRE, the increase was more rapid in the first half of the decade; for the Pap test and sigmoidoscopy, the increase was more rapid in the second half of the decade. Levels of colorectal cancer screening (both sigmoidoscopy and FOBTs) in 1998 were less than the level that prevailed a decade earlier for mammography. Patterns of change for all screening modalities differed between age, sex, and racial/ethnic groups, but prevalence of use during the study, within recommended time intervals, was consistently lower among groups with lower income and less education. Logistic regression analyses indicated that insurance coverage and, to a greater extent, usual source of care had strong independent associations with screening usage when age, sex, racial/ethnic group, and educational level were taken into account.

CONCLUSIONS

While cancer screening is generally increasing in the United States, usage is relatively low for colorectal cancer screening and among groups that lack health insurance or a usual source of care.

Mirrored-self misidentification: two cases of focal onset dementia

We present two patients in whom the mirror sign, the inability to recognize one's own reflected image, was a stable and persisting symptom signalling the onset of a progressive dementing illness. Extensive neuropsychological testing was conducted with both patients, with particular emphasis on face processing and the understanding of reflected space. Both patients were also investigated with structural imaging techniques (computed tomography and magnetic resonance imaging). Although the neuroimaging results were not strongly lateralizing for either patient, neuropsychological testing revealed striking right hemisphere dysfunction with relatively intact left hemisphere cognitive function in both patients. Of particular interest was the patients' dissociation on tests of face processing; one patient, FE, had significant face processing deficits while the other patient, TH, had relatively intact face processing. Further testing with TH revealed striking deficits in his ability to interpret reflected space. The results of the face processing tests are discussed in the context of current models of normal face processing, with particular emphasis on the affective component in face recognition. We propose that a combination of cognitive deficits underlie the mirror sign delusion, including perceptual, affective and reasoning impairments, and also discuss the contributions of cortical and subcortical lesions in these two patients and in delusions in general.

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium

BACKGROUND

In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care.

METHODS

A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318).

RESULTS

Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician.

CONCLUSIONS

Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.

A national census of ambulance response times to emergency calls in Ireland

BACKGROUND

Equity of access to appropriate pre-hospital emergency care is a core principle underlying an effective ambulance service. Care must be provided within a timeframe in which it is likely to be effective. A national census of response times to emergency and urgent calls in statutory ambulance services in Ireland was undertaken to assess current service provision.

METHODS

A prospective census of response times to all emergency and urgent calls was carried out in the nine ambulance services in the country over a period of one week. The times for call receipt, activation, arrival at and departure from scene and arrival at hospital were analysed. Crew type, location of call and distance from ambulance base were detailed. The type of incident leading to the call was recorded but no further clinical information was gathered. Results-2426 emergency calls were received by the services during the week. Fourteen per cent took five minutes or longer to activate (range 5-33%). Thirty eight per cent of emergencies received a response within nine minutes (range 10-47%). Only 4.5% of emergency calls originating greater than five miles from an ambulance station were responded to within nine minutes (range 0-10%). Median patient care times for "on call" crews were three times longer than "on duty" crews.

CONCLUSION

Without prioritized use of available resources, inappropriately delayed responses to critical incidents will continue. Recommendations are made to improve the effectiveness of emergency medical service utilisation.

Inner-city hospital closures in Dublin: implications for general practice

BACKGROUND

The Meath, Adelaide and National Children's Hospitals provided more than 300,000 ambulatory care episodes in 1996, half to residents of the adjacent inner-city postal districts. With the closure of the group in 1998, alternative care arrangements must now be provided.

AIMS

This paper examines the socio-economic and primary care characteristics of the communities most affected.

METHODS

Data on the 13 District Electoral Divisions surrounding the hospitals are drawn from a range of published sources.

RESULTS

The populations affected include 52% in social classes 5 to 7, have an average Standardised Mortality Ratio of 122, have high levels of GMS eligibility and include special care issues such as drug dependency. A total of 38 GPs cover the area. Other markers of deprivation are summarised.

CONCLUSION

The areas most affected by the closures have existing high levels of deprivation and social and medical need. Initiatives to respond to the closures must address these needs.

Use of cancer screening practices by Hispanic women: analyses by subgroup

OBJECTIVES

This study compares the use of three cancer screening practices (Pap smear, mammogram, and clinical breast examination) 3 years prior to interview among five subgroups of Hispanic women, and examines whether sociodemographic; access; health behavior, perception, and knowledge; and acculturation factors predict screening practices for any subgroup.

METHODS

Descriptive and multiple logistic regression analyses were conducted with data pooled from the 1990 and 1992 National Health Interview Surveys on women who reported that they were Hispanic. The study sample includes 2,391 respondents: 668 Mexican-American, 537 Mexican, 332 Puerto Rican, 143 Cuban, and 711 other Hispanic women.

RESULTS

Subgroup profiles reveal differences in education, health insurance, use of English language, and screening use. Mexican women were the least likely to be screened with any procedure. Logistic regression results for each screening practice show that having a usual source of care was a positive predictor for obtaining each of the three screening practices within the last 3 years. Being married, being more than 50 years of age, and having knowledge of breast self-examination were all predictors of having a Pap smear. Having health insurance and ever having had a clinical breast examination and Pap smear were predictors of having a mammography, while age, knowledge of breast self-examination, ever having had a Pap smear and mammogram, and being a nonsmoker all predicted having a clinical breast examination.

CONCLUSIONS

We conclude that access factors and prior screening are more strongly associated with current screening than are language and ethnic factors. Our data confirm that a disproportionate percentage of Hispanic women are low income and at risk of being underscreened. Our findings from a nationally representative sample of Hispanics have implications for provider practices, ethnic-specific community interventions, and future development of measures and data collection approaches.

Cancer prevalence and survivorship issues: analyses of the 1992 National Health Interview Survey

BACKGROUND/METHODS

Relatively little is known about the size and makeup of the growing population of cancer survivors or about the social implications of a diagnosis of cancer. To explore these issues, we analyzed cancer survivorship information from the 1992 National Health Interview Survey (NHIS), and resulting cancer prevalence estimates were compared with those derived from cancer registry data.

RESULTS

According to the NHIS, there were an estimated 7.2 million adult survivors of cancer-excluding nonmelanoma skin cancer-in 1992, representing 3.9% of the U.S. adult population. Comparisons with prevalence estimates from cancer registry data suggest that cancer is underreported in the NHIS. Nearly three fifths (58.0%) of cancer survivors self-identified on the NHIS reported that their cancer was first detected when they noticed something wrong and went to a doctor. The majority (55.7%) of cancer survivors had obtained a second opinion or multiple opinions regarding their treatment. Most (58.0%) had received patient educational materials from a health care provider. However, relatively few had received counseling or participated in support groups (14.2%), contacted cancer organizations after their diagnosis (10.9%), or participated in a research study or clinical trial as part of their cancer treatment (4.7%). One ninth (10.7%) of the survivors had been denied health or life insurance coverage because of their cancer. Nearly one fifth (18.2%) of the cancer survivors who worked before or after their cancer was diagnosed experienced employment problems because of their cancer.

CONCLUSIONS

While cancer appears to be underreported on the 1992 NHIS, the survey provides valuable information about the medical, insurance, and employment experience of cancer survivors selected from a nationally representative sample of U.S. households.

The relationship of socio-economic status and access to minimum expected therapy among female breast cancer patients in the National Cancer Institute Black-White Cancer Survival Study

Black women are more likely to be diagnosed with later stage breast cancer and have higher mortality rates from breast cancer than white women. To determine whether cancer treatment varies for white and black women, we analyzed data from the National Cancer Institute (NCI) Black-White Cancer Survival Study (BWCSS). Data from hospital medical records, central review of histology slides, and patient interviews on 861 breast cancer cases (in situ and invasive) were examined. Minimum expected therapy was defined for each disease stage as a basic minimum course of treatment that incorporated current practice, state-of-the-art knowledge, and recommendations advanced by NIH Consensus Conferences up to and including the one held in 1985. Patients in this study were diagnosed during 1985-1986. Using logistic regression techniques, those who received at least the minimum expected therapy were compared to those who did not. Thirty-six percent of the patients with late stage disease did not receive minimum expected therapy compared to four percent of the patients with early stage disease. Older women and women with no usual source of care were significantly less likely to receive minimum expected therapy. Overall, 21% of black women did not receive minimum expected therapy compared to 15% of white women.

Low income, race, and the use of mammography

OBJECTIVE

To describe national trends in mammography use by race and income and to test whether higher use of mammography among low-income African American women than low-income white women can be explained by health insurance coverage, usual place of health care, or place of residence.

DATA SOURCES/STUDY SETTING

Data from five years of the National Health Interview Survey spanning the period 1987-1994.

STUDY DESIGN

Trends in the percentage of women 50-64 years of age with a mammogram within the past two years were analyzed by race and income. Data for 1993-1994 were pooled, and with logistic regression analysis, variation in use of recent mammography for low-income women was investigated. Independent variables are age, race, family income, education, health insurance coverage, place of usual source of health care, metropolitan residence, and geographic region.

DATA COLLECTION/EXTRACTION METHODS

The National Health Interview Survey is a cross-sectional national survey conducted by the National Center for Health Statistics. Data are collected through household interviews. [Editor's note: in keeping with HSR policy, the term black is used to conform to its use in the surveys studied. In other references to race, the term African American is used.]

PRINCIPAL FINDINGS

Among women 50-64 years of age use of recent mammograms increased rapidly between 1987 and 1991 for all groups of women, and between 1991 and 1994 the increases slowed. However, increases between 1991 and 1994 have been more rapid among low-income black women than among low-income white women. In 1993-1994, low-income black women were about one-third more likely than low-income white women to report mammography within the past two years. This difference could not be explained by health insurance coverage, usual source of health care, metropolitan status, or region of residence.

CONCLUSIONS

These results, which provide some evidence of success for screening programs targeted to the poor, raise the question of why low-income black women appear to be to more likely than low-income white women to have benefited from recent efforts to promote mammography. Continued evaluation of mammography programs focused on women who are underserved as well as the monitoring of trends and variations in service use by race and income are needed.

Breast and cervical cancer screening interventions: an assessment of the literature

An extensive body of intervention research to promote breast and cervical cancer screening has accumulated over the last three decades, but its coverage and comprehensiveness have not been assessed. We evaluated published reports of these interventions and propose a framework of critical elements for authors and researchers to use when contributing to this literature. We identified all articles describing breast and cervical cancer screening interventions published between January 1960 and May 1997 in the United States and abstracted specified critical elements in the broad areas of: (a) needs assessment; (b) intervention study design; and (c) analysis methods and study outcomes from each article using a template developed for that purpose. Fifty-eight studies met our criteria for inclusion. Thirty-eight focused exclusively on breast cancer screening, 7 promoted cervical cancer screening, and 13 were designed to promote screening for both cancers. The amount of detail reported varied among the 58 studies. All studies reported the outcome measures used to assess the effectiveness of the intervention, yet only 40% of the studies reported the investigators' original hypotheses or research questions. Needs assessment data were reported in 84% of the studies. Data sources ranged from national surveys to local intervention baseline surveys. Population characteristics reported also varied, with most studies reporting age and race of the study population (78 and 71%, respectively), and fewer studies reporting income and education (53 and 38%, respectively). As the field of behavioral intervention research progressed, we found that more recent studies included and reported many of the parameters we had identified as critical. If this trend continues, it will enhance the reproducibility of studies, enable comparisons between interventions, and provide a reference point for measuring progress in this area. To facilitate this trend toward uniform reporting, we propose an evaluative framework of critical elements for authors to use when developing and reporting their research. The comprehensive assessment of literature that this article provides should be useful background to investigators planning and reporting cancer control interventions, to funding agencies choosing and guiding quality research, and to publishers to help them enhance the quality and utility of their publications.

Tobacco use among multi-ethnic Latino populations

OBJECTIVES

To examine tobacco use among New York City resident Latin Americans from different countries of origin and with different levels of acculturation reflected by language use.

DESIGN

Effective health promotion programs, particularly those aimed at smoking cessation and prevention, require careful investigation into possible cultural and societal factors influencing predictors and barriers to preventive health behavior. National data characterizing cigarette smoking behavior among broadly defined racial/ethnic groups (e.g., black, Hispanic) have rarely examined the extent or importance of cultural variation and acculturation within and among ethnic groups. This report addresses these issues.

METHODS

In this study, we examine self-reported cigarette smoking behavior from a 1992 telephone survey of a quota sample of Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics living in New York City. We compare results from these data with results from a random sample of New York City Hispanics from the Tobacco Use Supplement to the 1992-93 Current Population Survey.

RESULTS

Both data sets demonstrated that Puerto Ricans were significantly more likely to be current smokers and ever smokers than the other three Latino groups. Among Hispanic women in the quota sample, those who chose to complete the interview in English were much more likely to report ever smoking than those women who chose to complete the interview in Spanish.

CONCLUSIONS

The relationship between smoking behavior and acculturation (as measured by language usage) appears to be complex and sensitive to methodological issues of sampling and interview language.

The association between health care coverage and the use of cancer screening tests. Results from the 1992 National Health Interview Survey

OBJECTIVES

The authors investigated whether utilization of six different cancer screening tests (mammography, clinical breast exam, Pap smear, Fecal Occult Blood Test, and Digital rectal exam) varied according to type of health care coverage.

METHODS

Data on the use of cancer screening tests and coverage in two age groups from a 1992 nationally representative cross-sectional survey of approximately 9,400 adults were analyzed. Multiple logistic regression analysis was used to estimate proportions of persons screened according to type and extent of coverage, adjusted for socioeconomic, demographic, and health status characteristics.

RESULTS

Persons aged 40 to 64 years with Medicaid coverage were equally as likely to receive five of six cancer screening tests as those with private fee-for-service coverage, and both groups were much more likely to be screened (70% higher for all six tests) than those who had no coverage. In contrast, persons aged 65 years and older who had supplemental private fee-for-service insurance in addition to Medicare were more likely to receive five of six tests than those with Medicare and Medicaid or those with Medicare only. For all six screening tests, managed care enrollees at all ages were approximately 10% more likely to be screened than persons enrolled in private fee-for-service plans. Fecal Occult Blood Test (25% versus 20%) and digital rectal exams (44% versus 38%) in persons aged 40 to 64 years and mammography (59% versus 48%) and Fecal Occult Blood Test screening (38% versus 30%) in the elderly were significantly more frequent for persons in managed care plans.

CONCLUSIONS

The extent of fee-for-service insurance coverage in the traditional indemnity US health care system was positively associated with the use of cancer screening tests. The authors found less difference in use of cancer screening between managed care and fee-for-service care in 1992 than we expected based on earlier research comparing use of preventive services in health maintenance organizations with fee-for-service care.

Socioeconomic status and breast cancer mortality, 1989 through 1993: an analysis of education data from death certificates

OBJECTIVES

This study examined whether more highly educated women were at greater risk of dying of breast cancer during 1989 through 1993.

METHODS

Breast cancer mortality rates were calculated through death certificates and Current Population Survey data.

RESULTS

Breast cancer mortality rates were highest among women with 12 and with 16 or more years of education. Non-Hispanic Black women had the highest mortality rates and Asian women the lowest. Positive relationships between mortality and education were found for Hispanic women as well as non-Hispanic Black and Asian women.

CONCLUSIONS

The previously seen positive relationship between breast cancer mortality and education was found among US women of color but not non-Hispanic White women.

The effect of Medicare reimbursement for screening mammography on utilization and payment. National Cancer Institute Breast Cancer Screening Consortium

OBJECTIVE

In January 1991, Medicare extended its mammography benefit to reimburse for breast cancer screening mammograms. In 1991 and again in 1993, the National Cancer Institute Breast Cancer Screening Consortium (BCSC) conducted a survey to test the hypothesis that this benefit would increase mammography use among women over the age of 65.

METHODS

The authors analyzed data on non-Hispanic white women ages 65 to 74 living in 11 geographic areas targeted by the BCSC for an earlier study--six that had received cancer screening educational interventions and five control subsites--to measure the impact of the newly adopted Medicare benefit on the use of mammography and use of Medicare to reimburse mammography costs.

RESULTS

The data show little overall increase between 1991 and 1993 in reported mammography use among respondents to the survey. However, in six intervention and five control subsites there was an increase in the percentage of women who reported using public payment sources to at least partially reimburse the cost of mammograms. In three intervention subsites, the increase from 1991 to 1993 in the percentage of women using public sources of payment was greater than in the corresponding control subsites.

CONCLUSIONS

These findings suggest that public health interventions are more likely to succeed when educational promotion accompanies a financial benefit.

The use of home care by cancer patients: a multivariate analysis

The use of home care by cancer patients over the course of a year was analyzed using a two-part model that estimated: (1) the probability of any use, and (2) the quantity of visits given some use. The findings support the use of a two-stage model for estimating home care over single equation approaches. We found that while HMO membership increased the probability of some home care for cancer, it resulted in a smaller number of visits given some use. Health care coverage was also found to have different effects on these two components of total use. Some implications of some of these findings for future policies are discussed.

Stage of breast and cervical cancer diagnosis in disadvantaged neighborhoods: a prevention policy perspective

INTRODUCTION

Public health research on cancer and socioeconomic status (SES) has shown that higher SES is related to greater access to services. Using neighborhood-level measures of SES, we test hypotheses related to stage of breast and cervical cancer diagnosis.

METHODS

SEER data on women diagnosed with breast or cervical cancer in 1989 and 1990 in San Francisco, Atlanta, and Detroit were matched with 1990 Census tract data. Cases were grouped as "in situ" or "invasive" at diagnosis. Using multivariate logistic regression in two separate models, we investigated whether residence in a poverty-tract or, alternatively, a disadvantaged neighborhood is associated with increased likelihood of diagnosis with invasive tumors.

RESULTS

Living in a socioeconomically disadvantaged neighborhood was a strong, consistent predictor of invasive cancer. Living in a neighborhood with a high proportion of households in poverty was also a significant predictor for cervical cancer.

CONCLUSIONS

Our results suggest specific neighborhoods that would benefit from clinical interventions. Lack of economic and social resources constrains individuals living in these neighborhoods from taking advantage of interventions targeting individual behavior. Thus, interventions in the small proportion of disadvantaged neighborhoods, we argue, need to target the entire community. Further, policy reform at the community level becomes more feasible when need can be specified for a particular census tract.

Breast cancer control among the underserved--an overview

This paper explores barriers to the use of standard screening and breast cancer treatment that result in systematic differences in health outcomes. We review available data on individual, socioeconomic, and health system determinants of access to standard breast cancer care, including screening, diagnostic, and treatment services. Based on this review, we discuss the combination of factors which result in underservice. We argue that a broad framework which considers health system and social class as well as individual factors is useful for analyzing how structures of health care delivery tend to provide less than standard care to women who are older, have less income, or are less educated, black, or Hispanic. Data collection efforts which do not include structural and socioeconomic variables may result in an incomplete or misleading understanding of the determinants of underservice. These factors also need to be considered in the design and evaluation of public health policies and interventions meant to ameliorate the effects of underservice.

Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys

OBJECTIVES

Mammography rates reported by women in the National Health Interview Surveys of 1990 and 1987 are examined. Why this screening modality is not more frequently used is explored.

METHODS

Data from the 1987 and 1990 National Health Interview Surveys, conducted by the National Center for Health Statistics, are cross-tabulated and compared.

RESULTS

In 1987, approximately 17% of women over 40 years of age reported having had a screening mammogram in the previous year. In 1990, the rate doubled. Race declined in importance; income and education remained strong, positive predictors of screening.

CONCLUSIONS

Despite this dramatic increase, two thirds of women are not having screening mammograms. Use was not higher primarily because women did not realize that screening mammography tests for breast cancer in asymptomatic women. Primary care physicians are the main source of health education for screening mammography. The data suggest that public health programs to promote screening mammography should especially target primary care physicians and women with low incomes and education. Likewise, health care providers should ensure that their patients are referred to facilities that deliver high-quality mammography at low cost to make the procedure more accessible.

"Eat for Health": a supermarket intervention for nutrition and cancer risk reduction

OBJECTIVES

The results of an evaluation of "Eat for Health," a supermarket nutrition intervention, are presented. The study tested whether such a program could be successfully carried out and whether it could effect changes in knowledge, attitudes, and food purchasing behavior in line with nutrition and cancer risk reduction guidelines.

METHODS

The evaluation consisted of an in-store monitoring element, an in-store and telephone consumer survey, and an analysis of sales data on selected foods. A matched-pair design, using a total of 40 stores in the intervention and comparison groups, was used.

RESULTS

The intervention was successfully implemented and had limited success in changing some food purchasing behaviors. There appeared to be no effect on knowledge and attitudes except for increased awareness of a link between diet and cancer and of the program itself.

CONCLUSIONS

Despite the intervention's success, limitations of the consumer survey and sales data analyses and the continuing diffusion of nutrition messages throughout society make it difficult to specify the impact of this program on consumer nutrition knowledge and behaviors.