The effect of Iran's health transformation plan on hospital performance: Kerman province

Iran has performed Health Transformation Plan (HTP) from 2014 to obtain its defined goals. This study assesses and compares university and non-university hospitals' efficiency and productivity in Kerman provinces, Iran. The data of 19 selected hospitals, two years before and two years after Health Transformation Plan, was collected in this cross-sectional study. These data included the variables of physician and nurse number, and active beds as inputs and bed occupancy rate and inpatient admission adjusted with the length of stay as outputs. Data Envelopment Analysis method used to measure hospital efficiency. Malmquist Productivity Index is used to measure the efficiency change model before and after the plan. The efficiency and effect of the plan on hospitals' efficiency and productivity were assessed using R software. The results indicated that all hospitals' average efficiency before the HTP was 0.843 and after the HTP was increased to 0.874. However, it was not significant (P>0.05). Productivity also had a decreasing trend. Based on the DEA method results, it was found that university and non-university hospitals' efficiency and productivity did not increase significantly after the HTP. Therefore, it is recommended that attention be paid to hospitals' performance indicators regarding how resources are allocated and decisions made.

Racial-ethnic differences in prevalence of social determinants of health and social risks among middle-aged and older adults in a Northern California health plan

BACKGROUND

Social determinants of health (SDoHs) and social risks (SRs) have been associated with adverse health and healthcare utilization and racial/ethnic disparities. However, there is limited information about the prevalence of SRs in non-"safety net" adult populations and how SRs differ by race/ethnicity, age, education, and income.

METHODS

We analyzed weighted survey data for 16,247 White, 1861 Black, 2895 Latino, 1554 Filipino, and 1289 Chinese adults aged 35 to 79 who responded to the 2011 or 2014/2015 Kaiser Permanente Northern California Member Health Survey. We compared age-standardized prevalence estimates of SDoHs (education, household income, marital status) and SRs (financial worry, cost-related reduced medication use and fruit/vegetable consumption, chronic stress, harassment/discrimination, health-related beliefs) across racial/ethnic groups for ages 35 to 64 and 65 to 79.

RESULTS

SDoHs and SRs differed by race/ethnicity and age group, and SRs differed by levels of education and income. In both age groups, Blacks, Latinos, and Filipinos were more likely than Whites to be in the lower income category and be worried about their financial situation. Compared to Whites, cost-related reduced medication use was higher among Blacks, and cost-related reduced fruit/vegetable consumption was higher among Blacks and Latinos. Younger adults were more likely than older adults to experience chronic stress and financial worry. Racial/ethnic disparities in income were observed within similar levels of education. Differences in prevalence of SRs by levels of education and income were wider within than across racial/ethnic groups.

CONCLUSIONS

In this non-"safety net" adult health plan population, Blacks, Latinos, and Filipinos had a higher prevalence of social risks than Whites and Chinese, and prevalence of social risks differed by age group. Our results support the assessment and EHR documentation of SDoHs and social risks and use of this information to understand and address drivers of racial/ethnic disparities in health and healthcare use.

COVID-19 in Vietnam: A lesson of pre-preparation

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Slowing the spread of COVID-19 was initially achieved in Vietnam.

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Vietnam’s healthcare system put the precaution of COVID-19 to priority.

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Intensive and expansive contact, overall isolation, and sterilization should be implemented as soon as possible.

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Further measures are expected in light of different progressive scenarios of the disease.

Background

Vietnam was slowing the spread of COVID-19 to 200 cases by the end of March. From perspective of a relatively vulnerable healthcare systems, timely interventions were implemented to different stage of pandemic progress to limit the spread.

Method

The authors compiled literature on different public health measures in Vietnam in compared to the progression of COVID-19 from January to March 2020.

Results

Three stages of pandemic progression of COVID-19 were recorded in Vietnam. At 213 confirmed cases under treatment and isolation, a range of interventions were enforced including intensive and expansive contact, mass testing, isolation, and sterilization. Many were in place before any case were reported.

Conclusion

Preparation were key for Vietnam's healthcare system in the ever-changing landscape of COVID-19 pandemic.

Variation in Cold-Related Mortality in England Since the Introduction of the Cold Weather Plan: Which Areas Have the Greatest Unmet Needs?

: The Cold Weather Plan (CWP) in England was introduced to prevent the adverse health effects of cold weather; however, its impact is currently unknown. This study characterizes cold-related mortality and fuel poverty at STP (Sustainability and Transformation Partnership) level, and assesses changes in cold risk since the introduction of the CWP. Time series regression was used to estimate mortality risk for up to 28 days following exposure. Area level fuel poverty was used to indicate mitigation against cold exposure and mapped alongside area level risk. We found STP variations in mortality risk, ranging from 1.74, 1.44⁻2.09 (relative risk (RR), 95% CI) in Somerset, to 1.19, 1.01⁻1.40 in Cambridge and Peterborough. Following the introduction of the CWP, national-level mortality risk declined significantly in those aged 0⁻64 (1.34, 1.23⁻1.45, to 1.09, 1.00⁻1.19), but increased significantly among those aged 75+ (1.36, 1.28⁻1.44, to 1.58, 1.47⁻1.70) and for respiratory conditions (1.78, 1.56⁻2.02, to 2.4, 2.10⁻2.79). We show how spatial variation in cold mortality risk has increased since the introduction of the CWP, which may reflect differences in implementation of the plan. Combining risk with fuel poverty information identifies 14 STPs with the greatest need to address the cold effect, and that would gain most from enhanced CWP activity or additional intervention measures.

Multilevel modelling and public health policy

Background: Multilevel modelling is a statistical technique that extends ordinary regression analysis to the situation where the data are hierarchical. Such data form an increasingly common evidence base for public health policy, and as such it is important that policy makers should be aware of this methodology. Method: This paper therefore lays out the a basic description of multilevel modelling, discusses the problems of alternative approaches, and details the relevance for public health policy before describing which levels are relevant and illustrating the different kinds of hypotheses that can be tested using multilevel modelling. A series of examples is used throughout the paper. These relate to regional variations in the incidence of heart disease, the allocation of health resources, the relationship between neighbourhood disorder and mental health, the demand-control model in occupational health, and a school intervention to prevent cardiovascular disease.

Assessing Interorganizational Networks as a Dimension of Community Capacity: Illustrations From a Community Intervention to Prevent Lead Poisoning

Network analysis is often cited as a method for assessing collaboration among organizations as an indicator of community capacity. The purpose of this study was to (1) document patterns of collaboration in organizational networks related to lead poisoning prevention in a Native American community and (2) examine measurement issues in using organizational network analysis to assess community capacity. Interviews were conducted with representatives from 22 tribes, government agencies, schools, and community-based organizations in northeastern Oklahoma. Intensity, density, and reliability were assessed for several stages of collaboration. Intensity and density were greater for similar types of organizations than for the network as a whole and decreased as stage of collaboration increased. Network data were more reliable when responses were dichotomized than when intensities were compared. Mean reliability scores across two respondents from the same organization ranged from 60% to 90%. Results from network studies may help communities learn how to strengthen organizational networks to enhance community capacity.

Behavioral Health Services in the Changing Landscape of Private Health Plans

OBJECTIVE

Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care.

METHODS

A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care.

RESULTS

Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers' use of technology to improve care delivery, but this was not the norm.

CONCLUSIONS

Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.

Feasibility, utility and impact of a national dental epidemiological survey of three-year-old children in England 2013

Dental epidemiological surveys of children often focus on caries levels of five-year-olds as they are accessible and amenable to examination. Standardised surveys of this age group have been successfully carried out in the UK for many years. If improvements to caries level at age five are to be made then it is important to know when caries develops in the preceding years and what the likely causes are. This paper reports on the feasibility, utility and impact of a standardised survey of three-year-old children which took place in England.

METHOD

Standardised examinations were carried out on consented three-year-olds attending child care sites which had been randomly sampled using a method described in a national protocol. Feasibility was assessed by compliance results, utility from examples of use of the data and impact by a count of media responses at the time of publication.

RESULTS

Data from 53,814 examinations provided caries level estimates for 88% of lower tier local authorities, this number representing 8% of the population of this age cohort. Of the children for whom parental consent was provided, 8% refused to be examined at school and 9% were absent. The arising information was used in a variety of ways by local authorities and health planners. The media response was strong with coverage by TV, radio, printed press and online reporting.

CONCLUSION

This national survey of the oral health of three year olds was feasible but more labour intensive than surveys of school age children and the information derived has good utility and impact.

Use of action planning to increase provision of smoking cessation care by general practitioners: role of plan specificity and enactment

BACKGROUND

Strategies are needed to help general practitioners (GPs) promote smoking cessation as recommended by guidelines. This study examines whether the quality of action planning among GPs improves their provision of smoking cessation care.

METHODS

The effectiveness of a 1-h training programme was examined in a cluster randomised controlled trial in which 49 GPs participated. GPs who followed the training (intervention group; n = 25) formulated action plans related to i) enquiring about smoking, ii) advising to quit smoking, and iii) arranging follow-up for smokers motivated to quit. GPs also formulated a coping plan for encountering smokers not motivated to quit. The quality of these plans (plan specificity) was rated and, 6 weeks after the training, GPs reported on the performance of these plans (plan enactment). Multilevel regression analyses were used to examine the effects of plan specificity and plan enactment on patient-reported smoking cessation activities of the GPs in the intervention group (n = 1,632 patients) compared with the control group (n = 1,769 patients).

RESULTS

Compared to the control group, GPs who formulated a highly specific action plan during the training asked their patients about smoking more often after the training compared to prior to the training (OR 2.11, 95% CI 1.51-2.95). GPs were most likely to have asked patients about smoking after the training compared to prior to the training when they had enacted a highly specific formulated action plan (OR 3.08, 95% CI 2.04-4.64). The effects of GP plan specificity and plan enactment on asking patient about smoking were most prominent among GPs who, at baseline, intended to provide smoking cessation care.

CONCLUSIONS

A highly specific action plan formulated by a GP on when, how, and by whom patients will be asked about smoking had a positive effect on GPs' asking patients about smoking, especially when these professionals also reported to have enacted this plan. This effect was most prominent among GPs who intended to provide smoking cessation care prior to the intervention. Training in devising personalised coping plans is recommended to further increase GPs' provision of advice to quit smoking and arranging follow-up support to quit smoking.

Toward a population-based approach to end-of-life care surveillance in Canada: initial efforts and lessons

This paper describes a project undertaken by the Hospice Palliative End-of-Life Care Surveillance Team Network--one of four Cancer Surveillance and Epidemiology Networks established by the Canadian Partnership Against Cancer in 2009 to create information products that can be used to inform cancer control. The project was designed to improve the quality and use of existing electronic patient databases in its member organizations. The project's intent was to better understand terminally ill cancer patients in their final year of life, with noncancer as comparison. The network created an early design for a Web-based end-of-life care surveillance system prototype. Using a flagging process, anonymized data sets on cancer/ noncancer palliative patients and those who died in 2008-2009 were extracted and analyzed. The Australian palliative approach was adapted as the conceptual model based on the data sets available. Common data elements were defined then mapped to local data sets to create a common data set. Information products were created as online reports. Throughout the project, members were engaged in knowledge translation. Overall, the project was well received by network members. There are still major data-quality and linkage issues that require further work.

Health plan paid cost of epilepsy in 2009 in the U.S

Our objectives were to estimate the health plan paid cost of epilepsy and to show major cost driver(s) of these costs. The health insurance claims and membership data from six U.S. health plans were analyzed. To prepare two comparison groups, individuals with epilepsy (n=5810) were match-paired with individuals without epilepsy (n=5810) using propensity scores derived from logistic regression using gender, age group, health plan product, and length of enrollment in the health plans. Total health plan paid cost per member per year (PMPY) was $11,232 for the epilepsy group and $3026 for the controls (p<0.001). The estimated cost PMPY for treatment of epilepsy was $8206. Relative distribution (%) of health plan paid costs ($) by cost driver category based on place of service (POS) indicated that the treatment of epilepsy places a larger cost burden in inpatient POS than in outpatient hospital or MD office POS compared to controls.

The relationship of preparation for future care to depression and anxiety in older primary care patients at 2-year follow-up

BACKGROUND

: Preparation for future care needs has been hypothesized to help older adults adjust to inevitable life and health transitions and thereby decrease the likelihood of developing depression or anxiety.

METHODS

: A total of 190 primary care patients aged 65 years or more completed semistructured research interviews and mail-back surveys at study intake and 2 years later. Interviews included the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Hamilton Depression Rating Scale, Clinical Anxiety Scale and a measure of preparation for future care. Multiple regression analyses were used to determine the independent association of preparation for future care at intake with depression and anxiety severity at 2-year follow-up.

RESULTS

: Patients who had made more concrete plans at intake were less likely to meet criteria for depression diagnosis at follow-up. They also had lower anxiety severity scores. Patients who had avoided thinking about future care needs had greater depression symptom severity at follow-up. Findings were independent of potential confounds, including illness burden.

CONCLUSIONS

: Failure to prepare for future care is a novel putative risk marker for depression and anxiety in older adulthood. Clinicians should be aware that the lack of care planning and frank avoidance may pose a risk for depression and anxiety older their patients. Future research should explore the mechanisms of care planning's effects on subsequent mood.

[Management of arterial hypertension in Tunisia: the challenge of a developing country]

Tunisia is a north-African country where epidemiological and socio-economical transition lead cardio-metabolic diseases at the forefront of health concerns. Cardiovascular disease becomes the leading cause of death. Epidemiological studies noted that 30,6% of adults are hypertensive. Only 38,8% from those diagnosed with hypertension were aware about their disease. From those, 84% take antihypertensive treatment. Tunisian health authorities developed in 1993 a national program for diabetes and hypertension care. Hypertension benefits from a full support by the social security fund for policyholders and the state for the poor. Thus, hypertension followed by public health centers is controlled in 42.9% of cases.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries

BACKGROUND

Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country.

METHODS

We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality.

FINDINGS

Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals.

INTERPRETATION

We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent.

FUNDING

Bill & Melinda Gates Foundation, Norad, The World Bank.

Capturing the context of maternal deaths from verbal autopsies: a reliability study of the maternal data extraction tool (M-DET)

Background

The availability of quality data to inform policy is essential to reduce maternal deaths. To characterize maternal deaths in settings without complete vital registration systems, we designed and assessed the inter-rater reliability of a tool to systematically extract data and characterize the events that precede a nationally representative sample of maternal deaths in India.

Method/Principal Findings

Of 1017 nationally representative pregnancy-related deaths, which occurred between 2001 and 2003, we randomly selected 105 reports. Two independent coders used the maternal data extraction tool (questions with coding guidelines) to collect information on antenatal care access, final pregnancy outcome; planned place of birth and care provider; community consultation, transport, admission, hospital referral; and verification of cause of death assignment. Kappa estimated inter-rater agreement was calculated and classified as poor (K≤0.4), moderate (K = 0.4-≤0.6), substantial (K = 0.6-≤0.8) and high (K>0.8) using the criteria from Landis & Koch. The data extraction tool had high agreement for gestational age, pregnancy outcome, transport, death en route and admission to hospital; substantial agreement for receipt of antenatal care, planned place of birth, readmission and referral to higher level hospital, and whether or not death occurred in the intrapartum period; moderate to substantial agreement for classification of deaths as direct or indirect obstetric deaths or incidental deaths; moderate agreement for classification of community healthcare consultation and total number of healthcare contacts; and poor agreement for the classification of deaths as sudden deaths and other/unknown cause of death. The ability of the tool to identify the most-responsible-person in labour varied from moderate agreement to high agreement.

Conclusions

This data extraction tool achieved good inter-rater reliability and can be used to collect data on events surrounding maternal deaths and for verification/improvement of underlying cause of death.

Health plan resource use: bringing us closer to value-based decisions

OBJECTIVE

To examine commercial health plan variation in resource use for members with diabetes and its relationship to the quality of care for these members.

STUDY DESIGN

Cohort study using National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set data submitted to the NCQA in 2007, reflecting 2006 health plan performance. Data are submitted to the NCQA by plans based on claim and administrative data; medical record data may be used to supplement missing claim data.

METHODS

Composite measures for diabetes quality and resource use (total medical care observed-to-expected [O/E] and pharmacy O/E variables) were estimated. Descriptive statistics, Pearson correlations between quality and resource use, and 90% confidence intervals around each health plan's composite quality and resource use results were estimated.

RESULTS

Vast variation was found for both quality and resource use. Medical care resource use has no relationship to quality for diabetes. Pharmacy resource use has a moderate positive relationship to quality.

CONCLUSIONS

Measures of resource use, along with measures of quality, can be produced and provide important information about the value of a health plan. Although this analysis did not determine causality, the lack of relationship between quality and resource use suggests that plans could improve quality of care without large increases in resource use or could achieve the same level of quality with less resource use.

Design and development of a web-based Saudi National Diabetes Registry

BACKGROUND

Given that diabetes is an extremely common disorder in Saudi Arabia, the National Diabetes Registry was designed by King Saud University Hospital Diabetes Center in collaboration with King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in the year 2001. The aim of the registry is to identify risk factors related to diabetes and to provide statistics to public health programs and health care professionals for use in planning and evaluation. The registry was designed to provide information on the extent and nature of specific types of diabetes, diabetes complications, and treatment of diabetes in the Kingdom. The registry has been available since 2001, with major collaborations from 26 hospitals as part of Phase I in which 100,000 patient data is to be collected on a regional level from Ar-Riyadh before extending the program to other regions of Saudi Arabia.

METHODS

The web application was designed using relational database techniques along with on-line help topics to assist users to get acquainted with application functionalities. All Internet forms were designed with validation checks and appropriate messages to ensure quality of data. The security measures established within the application ensure that only authorized users can gain access to the functionalities of the registry at allowed times. Administrative features were designed to manage the registry-related operations easily.

RESULTS

The diabetes registry has been in operation for almost 10 years, and around 67,000 patients have been registered to date. The Web-application offers an anytime-anywhere access to the registry's data, removing geographical boundaries and allowing the national registry to provide real-time data entry, updates, reporting, and mapping functionalities more easily.

CONCLUSION

Merging related information in the form of databases can provide improved health care operations through instant access to data, ease of managing complex data structures, and creation of reports to be used by health care planners and hospital administrators.

Paediatric pandemic planning: children's perspectives and recommendations

Children, as major stakeholders in paediatric hospitals, have remained absent from discussions on important healthcare issues. One critical area where children's voices have been minimised is in the planning for future pandemics. This paper presents a subset of data from a programme of research which examined various stakeholder experiences of the severe acute respiratory syndrome (SARS) outbreaks of 2003. These data also generated recommendations for future pandemic planning. Specifically, this paper will examine the perspectives and recommendations of children hospitalised during SARS in a large paediatric hospital in Canada. Twenty-one (n = 21) child and adolescent participants were interviewed from a variety of medical areas including cardiac (n = 2), critical care (n = 2), organ transplant (n = 4), respiratory medicine (n = 8) and infectious diseases (patients diagnosed with suspected or probable SARS; n = 5). Data analyses exposed a range of children's experiences associated with the outbreaks as well as recommendations for future pandemic planning. Key recommendations included specific policies and guidelines concerning psychosocial care, infection control, communication strategies and the management of various resources. This paper is guided by a conceptual framework comprised of theories from child development and literature on children's rights. The authors call for greater youth participation in healthcare decision-making and pandemic planning.

The pandemic influenza planning process in Ontario acute care hospitals

BACKGROUND

There will be little time to prepare when an influenza pandemic strikes; hospitals need to develop and test pandemic influenza plans beforehand.

METHODS

Acute care hospitals in Ontario were surveyed regarding their pandemic influenza preparedness plans.

RESULTS

The response rate was 78.5%, and 95 of 121 hospitals participated. Three quarters (76.8%, 73 of 95) of hospitals had pandemic influenza plans. Only 16.4% (12 of 73) of hospitals with plans had tested them. Larger (chi(2) = 6.7, P = .01) and urban hospitals (chi(2) = 5.0, P = .03) were more likely to have tested their plans. 70.4% (50 of 71) Of respondents thought the pandemic influenza planning process was not adequately funded. No respondents were "very satisfied" with the completeness of their hospital's pandemic plan, and only 18.3% were "satisfied."

CONCLUSION

Important challenges were identified in pandemic planning: one quarter of hospitals did not have a plan, few plans were tested, key players were not involved, plans were frequently incomplete, funding was inadequate, and small and rural hospitals were especially disadvantaged. If these problems are not addressed, the result may be increased morbidity and mortality when a virulent influenza pandemic hits.

Use of finite element analysis in presurgical planning: treatment of mandibular fractures

BACKGROUND

The current clinical procedure for mandible fracture fixation is plate application. 3D reconstructions are used to validate procedures numerically preceding experimental analysis. This study outlines the methods used to reconstruct a numerical model of the mandible.

METHODS

A CT scan from a 22-year-old male patient with a healthy unfractured mandible was obtained. A 3D reconstruction was carried out using Mimics via thresholding and segmentation techniques. Boundary conditions and muscle forces were applied, and simulations were performed using ABAQUS.

RESULTS

3D reconstruction allows for precise anatomical dimensions, which can be used for further engineering analysis. Using the surgical Champy technique as an example, results showed that the mandible model returned to normal function post-plating.

CONCLUSIONS

The study shows the clinical relevance of 3D reconstructions to plan surgical procedures. Results illustrate the benefit of carrying out numerical validations as a prerequisite to experimental modelling and as a method of pre-validating surgical procedures.

Diversification in the hospital industry

An institution life cycle hypothesis is advanced to explain hospital behavior: boom and bust, diversification and divestiture, occasionally leading to closure or merger. Hospital diversification and its impact on the operating ratio are studied for 172 hospitals during the period 2002-2007. Diversification and operating ratio are modeled in a two-stage least squares (TSLS) framework as being jointly dependant. Institutional diversification is found to yield better financial position, and the better operating profits allow the institution the wherewithal to diversify. The impact of external government planning and hospital competition is also measured. Some services are in a growth phase, like bariatric weight loss surgery and sleep disorder clinics. Management's attitude concerning risk and reward is considered.

Evaluation of social support among surgical cardiac patients: support for nursing care planning

This descriptive and cross-sectional study aimed to measure social support among subjects hospitalized for surgical treatment of cardiac diseases and to verify the relations between social support and socio-demographic variables. Data were collected between May, 2004 and June, 2005. A total of 86 patients were studied, 47 men, 58 married and the average age was 53 years old. Regarding social support, in an interval from 1 to 5, we found an average of 4.2+0.74 (interval of 1.92 to 5) for the emotional support and 4.2+0.6 (interval of 2.3 to 5) for the instrumental support, which indicate high satisfaction and availability of received supports. We found weak but statistically significant correlations between instrumental and emotional supports and the participants' age and between instrumental support and years of education. We did not find any differences in the perception of social support in terms of participants' gender and marital status.

An implementation intentions intervention to increase uptake of mammography

BACKGROUND AND PURPOSE

This study tested an implementation intentions intervention to increase uptake in the United Kingdom's National Health Service Breast Screening Programme. The intervention asked women to plan how they would overcome up to 3 previously identified barriers to attending.

METHODS

In a randomized controlled trial, 2,082 participants were allocated to an intervention condition, an assessment-only condition, or a nonassessment control condition. The intervention condition was designed to help women plan how to change their appointment, how to arrange transport, and how to negotiate time off work. The assessment-only condition controlled for the possibility that completing a questionnaire about mammography might in itself influence attendance, and the nonassessment condition was a control against any effect on attendance that mere contact with the research team might have.

RESULTS

Mean age of respondents was 56.1 years, and 99.4% were White British. In the full intention-to-treat analysis, which included all participants, attendance was found to be almost identical across the 3 conditions, around 80%. Some of the women in the intervention condition, however, failed to write their plans on the questionnaire (10.6% for changing the appointment, 2.1% for travel arrangements, and 21.1% for taking time off work) or said that planning was irrelevant to them (2.4% for changing the appointment, 1.7% for travel arrangements, and 32.4% for taking time off work). A second analysis, of planning time off work, therefore, examined the 620 respondents in the intervention condition more closely and found that those who planned were significantly more likely to attend than those who did not. A 3rd analysis, excluding the 209 respondents for whom planning time off work was irrelevant, revealed that the most likely to plan were those whose initial intentions to attend were strong but whose perceptions of control over making the necessary arrangements to attend were weak.

CONCLUSIONS

Two main implications of the findings are discussed: the importance of planning in implementation intentions interventions and the validity of the theoretical distinction between motivation and volition.

Comparison of two widely used PTSD-screening instruments: implications for public mental health planning

Epidemiological research serves a critical role in public mental health planning in the aftermath of disasters, particularly via estimation of the mental health burden and potential needs of affected communities. However, different measures are used across studies to assess mental health response, making cross-study comparison difficult. The National Women's Study Posttraumatic Stress Disorder module (NWS-PTSD) and PTSD Checklist (PCL) have been among the most widely used measures of PTSD in postdisaster research. Here, the authors used a sample of 233 New York City-area residents who were administered both the NWS-PTSD and PCL 4 months after the September 11, 2001 terrorist attacks. The PCL yielded higher prevalence estimates at the symptom, cluster, and diagnostic levels. Implications for the interpretation of epidemiological data are discussed.

Shared decision making for in-patients with schizophrenia

OBJECTIVE

Patients' participation in treatment planning is being increasingly advocated in mental health. The model of "Shared Decision Making" (SDM) is proposed as a promising method of engaging patients in medical decisions and improving health-related outcomes. In the present study, the feasibility and effects of SDM for in-patients with schizophrenia should be evaluated.

METHOD

Randomized controlled trial comparing a SDM program with routine care (n = 107).

RESULTS

The intervention studied was feasible for most of the patients and did not take up more of the doctors' time. Patients in the intervention group had a better knowledge about their disease (P = 0.01) and a higher perceived involvement in medical decisions (P = 0.03). The intervention increased the uptake of psychoeducation (P = 0.003).

CONCLUSION

Sharing medical decisions with acutely ill in-patients with schizophrenia is in many cases possible and improves important treatment patterns. This might help in destigmatizing this group of patients and improving schizophrenia-related health outcomes.

[Psychiatric care in South Tyrol -- an example of coordination]

The Tyrol's division after the two World Wars cut the South Tyrol off from every relevant aspect of psychiatric care. First attempts towards a community psychiatric system weren't sufficiently sustained by politicians. Only in the 90 ty's was the association of relatives of mentally ill people able to sensitize public and politicians to the need for an adequate psychiatric care system. Since 1996 an excellent psychiatric plan has been in existence, 80 % of which has to date been able to be put into practice. Since 1997 mentally ill people have founded their own self-help-organization and influenced the planning process.

An epidemiological study of head injuries in a UK population attending an emergency department

We aimed to identify the attendance rate for all head injuries, and for moderate to severe head injury (MSHI), in an emergency department (ED), and related risk factors for MSHI, including age, sex, area of residence, and socioeconomic status (SES). This was a retrospective descriptive epidemiological study of an ED database of head injury attendances over 6 years, carried out in an ED that serves both urban and mixed rural and urban areas, with a wide socioeconomic range, and a total population of 344,600. The main outcome measure was rates of attendance for head injury. Head injury presentations accounted for 3.4% of all attendances per year. An overall rate of 453 per 100,000 was found for all head injuries, of which 40 per 100,000 were moderate to severe (10.9%). Urban residents had significantly greater risk of presenting with MSHI compared with residents of mixed/rural areas. Males were more at risk than females, and children and adolescents had higher risk of MSHI. A high attendance rate of MSHI was found in the <5 year old age group in urban areas for both sexes. A gradient, with higher attendance in groups with lower SES, was observed for children in urban areas, while the gradient was reversed in mixed/rural areas. Head injuries are a relatively common cause of attendance at ED. There is significant variation in attendance with MSHI with regard to sex, age, socioeconomic factors, and type of area of residence. The planning and delivery of preventative and management services may be improved by such analyses.

An epidemiologically-based needs assessment for stroke services

Stroke is amenable to the entire spectrum of health services, ranging from prevention of its risk factors, to the treatment of acute stroke and rehabilitation and palliation of stroke. The aim of this study was to determine the number of persons with the capacity to benefit from evidence-based effective stroke services. Population-based survey and registry data along with published, evidence-based recommendations for services were used to determine the number of persons in Eastern Ontario with stroke (including risk factors, acute stroke and chronic stroke) and their related need for services (including prevention programs, diagnostic services, treatment of acute stroke and rehabilitation). These estimates were then compared to the actual provision of these services. Estimates of the need for effective services exceeded the provision of all services with the exception of pharmacologic treatment for diabetes mellitus and carotid endarterectomy for acute stroke. The approach was able to identify both the under-provision and over-provision of evidence-based effective services for stroke. This study has shown that an epidemiologically-based needs assessment could be a useful basis for the planning of health services.

Towards a needs based mental health resource allocation and service development in rural and remote Australia

OBJECTIVE

To develop a transparent, needs-based mental health resource allocation framework to guide area level service planning in rural and remote settings.

METHODS

Using the Central Australian mental health service region as a case study, a five-step approach was used to analyse and gather relevant data as follows: (i) mapping a regional sociodemographic profile; (ii) estimating the expected level of mental illness within the regional population; (iii) estimating the expected level of specialist mental health service usage; (iv) estimating the expected categories of specialist mental health care required for the regional population; (v) making adjustments to the costs of providing specialist mental health care on the basis of demographic features of the region. These data were then matched with the availability, access and cost of specialist mental health care currently provided at the regional level.

RESULTS

The capacity of specialist mental health care in Central Australia was below the expected benchmark for the population residing in this region. The region required approximately double the existing funding allocation to provide an adequate and equitable level of care that meets the needs of the diverse population groups. Children and adolescents were the group most in need, as were adult Aboriginal people living in remote settings.

CONCLUSION

The framework described provides the beginnings of more open and transparent evidence-based decision-making regarding mental health resource allocation and service development for rural and remote residents.

["Proportion of contact"--an alternative attempt to estimate health care needs]

The Swedish Health and Medical Care Act declares that health and medical care should be planned according to the needs of the population. Assessments of health care needs should begin with the total need of health care for any given population since the different forms of health care are dependent on each other. In Sweden, information on utilisation of care could estimate immediate short term health care needs. Individual self-perceived ill health is a reasonable basis for measures of health care needs, allowing for the fact that individuals often are in contact with several different forms of health care. Information regarding the 1.5 million individuals of the Västra Götaland Region and the associated utilisation of different forms of health care were collected for 2000 and 2001 . The proportion of contact is defined as the proportion of unique individuals from a specified geographical area who have been in contact with the health care system during a specified period of time. Each form of health care and the combinations thereof are regarded as a distinct category. The proportion of contact could be regarded as an estimate of the immediate overall self-perceived health care need and a reasonable measure for further studies on how to allocate resources.

Introduction: Geographic Information Systems in Public Health and Medicine

Geographic information systems (GIS) are increasingly being used in public health and medicine. Advances in computer technology, the encouragement of its use by the federal government, and the wide availability of academic and commercial courses on GIS are responsible for its growth. Some view GIS as only a tool for spatial research and policy analysis, while others believe it is part of a larger emerging new science including geography, cartography, geodesy, and remote sensing. The specific advantages and problems of GIS are discussed. The greatest potential of GIS is its ability to clearly show the results of complex analyses through maps. Problems in using GIS include its costs, the need to adequately train staff, the use of appropriate spatial units, and the risk it poses to violating patient confidentiality. Lastly, the fourteen articles in this special issue devoted to GIS are introduced and briefly discussed.

Time for a new approach to medical workforce planning

There are concerns that Australia is facing an impending shortage in the medical workforce, and there are significant changes occurring in key determinants of medical workforce supply and demand. To date, workforce planning has not taken into account the full range of dynamic variables that are involved, nor accounted for their inherent uncertainty and complex interactions. Future planning will require more careful monitoring and dynamic modelling within a full healthcare system perspective.

National and regional differences in preparation for future care needs: a comparison of the United States and Germany

Planning for future care needs is likely to be influenced by both policy and culture. We compared attitudes regarding the usefulness of planning ahead for future care needs, processes of preparation for these needs (becoming aware of the risk of future care needs, gathering information about available options, deciding on preferences, concrete planning), and outcomes of preparation (e.g., knowledge about services) in 294 East German, 288 West German, and 590 American seniors. American respondents had higher preparation scores. Compared to the size of national differences, differences between East and West German seniors were generally smaller. East Germans made fewer decisions on preferences and engaged in less concrete planning. Most of the national and regional differences in preparation for future care needs were reduced or eliminated by controlling for differences in the perceived usefulness of planning.

Mapping caries prevalence and water distribution in Wales-- Iechyd Morgannwg Health Authority as a case study

STUDY OBJECTIVE

To investigate the use of mapping in targeting water fluoridation to areas of high need in lechyd Morgannwg Health Authority, as defined by the upper quintile of the distribution of the percentage with dmft > 0 in dental planning areas.

DESIGN

Data from the 1997/98 childhood dental epidemiological survey and the Welsh Water Company water supply zones (as at 1997) were plotted. Maps were generated to identify the relationship between water supply areas, water supply sources and areas of high caries prevalence.

SETTING

Maps focussed upon one Welsh health authority, Iechyd Morgannwg Health Authority. Examinations for the childhood epidemiology programme took place in schools.

PARTICIPANTS

5-year-old children examined in the 1997/98 survey.

MAIN RESULTS

Data presented by very different geographical boundaries were compared without having to carry out complex mathematical transformations. It was possible to quickly identify areas of Iechyd Morgannwg Health Authority with high levels of oral disease, the associated water supply zones and their water treatment centres with a view to possible future targeting of fluoridation. The maps identify the possibility of dilution, when a particular water supply zone was served by more than one treatment works.

CONCLUSIONS

This technique enables disparate and complex data bases to be combined enabling visual analysis of the results. The maps facilitate decision making as to the most beneficial areas to fluoridate. The results will be of value in determining the feasibility and targeting of water fluoridation in Wales.

Analysis model for planning chemical dependence treatment systems

Statewide needs assessments commonly generate a single estimate of the number of persons needing chemical dependence treatment. The present analysis utilizes help-seeking behavior models and patient placement concepts to break a single statewide need estimate into operational units of services and costs that can be used for planning and resource allocation. The analyses are presented as allocation models for placements, service populations, service capacities, and costs. The guide was tested using state data for a target year and the results were compared to actual treatment admissions, which revealed a lack of convergence. Only 9% of persons were estimated to need intensive residential treatment whereas actual admissions to intensive residential treatment accounted for 29% of all admissions. The disparities may be accounted for by sampling bias of the needs estimate and by the likelihood that persons with more severe problems may be overrepresented when only a small proportion of treatment need is being met. These findings suggest that if resources become available to narrow the treatment gap, a larger proportion of outpatient services and less intensive services may be appropriate for the expanded clientele.

Does preventive health care have a chance in the changing health sector in Tanzania?

OBJECTIVE

To investigate the status and practice of preventive health care (relative to curative) in the health delivery system at the time when the health sector reforms are taking place.

DESIGN

A cross-sectional, descriptive study.

SETTING

The study was conducted in Morogoro District between January and May 1999.

SUBJECTS

Eighty six medical personnel and two hospital administrators from thirty four health facilities. The health facilities included twenty five dispensaries, five health centres and four hospitals. Care was also taken to include health facilities owned by various institutions and organisations, including governmental and non-governmental.

RESULTS

Generally, preventive health received little attention compared to the curative health measures whereby more than 80% of the medical personnel in some of the facilities were assigned to curative services. Health personnel reported to spend an average of up to six hours per day providing curative services such as chemotherapy, surgical treatment, psychotherapy and radiography. On the contrary, they spent about four hours or less on providing child immunisation and education on nutrition, health and family planning. As expected, the type of ownership of a health facility influenced the extent to which preventive measures were included. For example, while all the government owned facilities did provide child immunisation, nutrition education and family planning services, some non-governmental facilities were lacking such services.

CONCLUSION

It is obvious that while the provision of curative health care can be left to the hands of the private suppliers, that of preventive health care needs strong government involvement. It is suggested that deliberate efforts be taken to shift resources from curative to preventive measures. One way in which such a strategy can be attained is for the government to set, as a condition for private operators, a minimum level of preventive measures to be provided by every operator before a permit is issued. However, caution should be taken to ensure that such deliberations do not discourage investors in the health sector.

Systematic review of incidence studies of Parkinson's disease

Incidence studies of Parkinson's disease (PD) are important for both health-care planning and epidemiological research. This report reviews the methods and results of previous incidence studies of PD and makes recommendations for future studies. Original articles that described the incidence of PD were located using several strategies. The methods were summarised, and the results of studies with similar methodologies were compared on a standardised population. Twenty-five incidence studies were included. Each used different methods to identify incident patients, although most screened both primary care and hospital records. Only eight studies were prospective, and only two of these had any follow-up. The diagnostic criteria for PD varied (11 studies used two or more cardinal motor features, four used the UK Brain Bank criteria), as did the exclusion criteria and the definition of an incident case. In 16 studies, attempts were made to confirm the diagnosis by examination of patients by a specialist as part of the study. None of the studies used identical methods, but five were sufficiently similar to merit comparison. Four of these gave a similar incidence (16-19/100000/year), but one from Italy had a much lower incidence (8.4/100000), the reason for which was unclear. Five studies found significantly greater incidence in men. This review highlights the difficulties in performing good quality incidence studies of PD. Further incidence studies using standardised methods are required. A set of minimal scientific criteria has been devised to improve the quality and consistency of future studies.

Providers issue brief: certificate of need: year end report-2002

At one time, every state was required by the federal government to have a certificate of need (CON) program. The process was intended to keep down costs associated with the construction of new health facilities in the state, and prevent over development. When the federal requirement was lifted, however, a number of states did away with their programs. Some later restored them in some form, and many have kept their programs alive for years, requiring a governmental seal of approval for building new facilities such as hospitals and long-term care facilities or for acquiring major medical equipment.

Small area comparisons of health: applications for policy makers and challenges for researchers

It is a challenge to researchers to present their results in a way that serves the needs of health policy makers. Small area maps of life expectancy provide an insightful presentation. In this study, we pursued small area comparisons on a scale that is smaller than is currently available on a province-wide basis. We visualized Nova Scotia's provincial variation in health and identified the Cape Breton Regional Municipality and Halifax's disadvantaged "North End" neighbourhood as areas with major health concerns. The observed health differences are only partially explained by socioeconomic factors such as income and unemployment. The study also demonstrated the feasibility of small area comparisons at the level of census consolidated subdivisions and neighbourhoods. There are various methodological challenges for researchers, however: allocation procedures such as the postal code-conversion-file may introduce substantial error; the application of appropriate spatial smoothing procedures is crucial to the interpretation of regional variation in health; and the migration of frail individuals to nursing homes affects the geographic variation in health.

Using DEA to evaluate efficiency and formulate policy within a Greek national primary health care network. Data Envelopment Analysis

The purpose of this paper is to critically evaluate the relative efficiency of primary health care centers of the principal Greek public insurance provider, the Social Security Institute (IKA). The source of the efficiency data was the Statistical Unit of IKA. Using Data Envelopment Analysis, we analyzed data from 133 centers nationwide. Input variables included the number of personnel, stratified in different categories, and the number of people covered by each health center. The number of pensioners enlisted to each health care facility was used as an index of aging and vulnerability of the covered population. According to the results of the study, centers with the technological infrastructure to perform laboratory and/or radiographic examinations exhibited higher efficiency scores. In addition, centers with eligible covered populations from 10,000 to 50,000 were found as the most efficient. Health sector reforms should be planned on the basis of such analyses. If the model is supplemented with valid demographic, socioeconomic, and epidemiological data, it may become the basis for the creation of a national health care chart, matching available resources to the population and its health care needs.

Mesoamerica Nutrition Program Targeting Study Group. Targeting performance of three large-scale, nutrition-oriented social programs in Central America and Mexico

This study evaluated whether three nutrition-oriented programs in Central America and Mexico have been successful in targeting those households most vulnerable to undernutrition and poverty. For each country, nationally representative data sets were used to estimate cutoff points dividing the population into 10 equal-sized groups according to child anthropometric measurements (age-standardized height) and household income (per capita household expenditures). Households meeting eligibility criteria were then assessed using special baseline surveys or national data obtained before implementation of the program. Children in these households were classified according to national deciles of height-for-age, and households were classified according to expenditure deciles. In spite of markedly differing targeting strategies, each of the programs was well targeted, with 45% (Honduras and Mexico) and 52% (Nicaragua) of children in eligible households coming from the lowest two deciles of the national distributions, and virtually none from the upper two deciles. Similar results pertained to household income. These experiences demonstrate that vulnerable households can be targeted relatively straightforwardly, and that the need to do this does not in every case imply household-level income screening.

The 80:20 phenomenon: help or hindrance to planning caries prevention programmes?

OBJECTIVE

to compare the outcomes of population segmentation analyses according to caries experience using the distribution of dmft and the Super Profiles geodemographic classification.

BASIC RESEARCH DESIGN

The study population consisted of all 15,747 children in seven districts in the North West Region, England who were examined in whole population surveys during the 1995/6 NHS epidemiological survey of 5-year-old children. Market penetration analyses were used to segment this population according to caries experience by their dmft score and by the Super Profiles geodemographic classification. Lorenz curves were plotted and Gini coefficients were calculated from the outputs.

MAIN OUTCOME MEASURES

When dmft was used to segment the population approximately 80% of carious teeth were found in some 42% of the total population, producing a Lorenz Curve with a Gini coefficient of 66%. The population was then segmented using Super Profiles Target Markets. The target markets were ranked according to caries experience and the denominator population living in each of these area types. Some 81% of the total population dmft was found in the topmost ranked 73.8% of the total population. The resultant Lorenz curve produced a Gini coefficient of 16.2%.

CONCLUSIONS

About half of the population disease was confined to a minority of the population but not to the extent of 80% of the disease in 20% of the population. Although these high risk children were more commonly found in underprivileged area types, they did not live exclusively in a small number of deprived areas. These findings shed doubt on the wisdom of a targeted approach to oral health promotion and disease prevention programmes.