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Biomedical subjects

A Mills

Publications and source records attributed to A Mills.

At least 37 records · Page 2Linked to original sources
PubMed1999

Profit, payment and pharmaceutical practices: perspectives from hospitals in Bangkok.

Means by which to improve the quality of care offered in the private sector have received increasing interest. This paper considers the influences upon hospital physician prescribing practices. It presents data on drug management practices and prescribing patterns in a sample of private for-profit, private non-profit and public hospitals in Bangkok. Clear differences emerge in prescription patterns between the different groups of hospitals: public hospitals exhibit greater use of essential drugs and generic prescribing than either group of private hospital, and prescriptions at private for-profit hospitals tended to have more essential drugs and drugs prescribed by generic name than non-profit hospitals. Prescribing patterns in public hospitals are probably largely explained by national government policy on pharmaceutical procurement. In contrast, prescribing patterns in private for-profit hospitals appear heavily influenced by pressure upon management to contain costs, in circumstances where high drug costs cannot be passed on to purchasers. Hence hospital management have developed policies encouraging the use of generic drugs and essential drugs. These same financial pressures also explain some less desirable forms of behaviour in private for-profit hospitals such as prescribing courses of antibiotic treatment of extremely short duration. Possible measures which government may take to encourage appropriate prescribing within private hospitals are discussed.

Data Collection↗
PubMed1999

Rebound mortality and the cost-effectiveness of malaria control: potential impact of increased mortality in late childhood following the introduction of insecticide treated nets.

The efficacy and relative cost-effectiveness of insecticide-treated nets (ITNs) for the control of malaria in children under 5 years of age have recently been demonstrated by several large-scale trials. However, it has been suggested that long-term use of ITNs in areas of high transmission could lead to mortality rebound in later childhood, which would reduce the cost-effectiveness of the intervention, and at the extreme could lead to negative overall effects. A model is presented in which the cost and disability adjusted life years (DALYs) per child aged 1-119 months were estimated for a sub-Saharan African population with and without an ITN intervention. The rebound rate, defined as the percentage increase in age-specific all-cause mortality and malaria specific-morbidity, was varied to estimate the threshold at which the intervention was no longer cost-effective. Rebound was considered over two possible age ranges: 5-9 years and 3-6 years. With mortality and morbidity reductions due to ITNs in children aged 1-59 months and rebound in the 5-9 years age class, one could be reasonably certain that the cost per DALY averted is below $150 up to a rebound rate of 39%. Up to an 84% rebound rate it is highly likely that the intervention will be DALY-averting, that is the DALYs averted by the intervetion outweigh DALYs incurred through rebound effects. These thresholds are sensitive to the age range over which reductions and rebound in morbidity and mortality occur. With reductions confined to children aged 1-35 months and rebound in the 3-6 years age class, the cost per DALY is highly likely to fall below $150 only up to a 2.5% rebound rate, and with a rate in excess of 11% one can no longer be reasonably certain that the intervention is DALY-averting. These rates apply to the whole population. If there is no rebound amongst children who did not comply with the intervention, the actual increases in morbidity and mortality required to reach these thresholds amongst compliers would be much higher. The age range over which rebound occurs is a critical determinant of the thresholds at which one can no longer be reasonably certain that ITNs remain cost-effective in the long term. Based on empirical estimates of age-specific malaria mortality in sub-Saharan Africa, it appears unlikely that this threshold rate would be reached if rebound occurs over the 5-9 years age range. By contrast, if rebound occurs over the ages of 3-6 years, the increase in mortality rates required to reach this threshold falls within the observed range of malaria-specific mortality rates for this age group. It is essential that long-term surveillance is included as part of ITN interventions, with particular attention to the age range over which rebound may occur.

Africa South of the Sahara↗
PubMed1999

Evaluating payment mechanisms: how can we measure unnecessary care?

There has been substantial concern that linking hospital or physician remuneration to the amount of care provided will encourage excessive provision of health care. Studies that seek to explore this relationship require methods to measure unnecessary care. This paper presents and discusses a method used to assess the magnitude of unnecessary care in the context of an evaluation of the impact of paying bonuses to physicians employed in public hospitals in Shandong Province, China.

Adolescent↗
PubMed1999

Patient satisfaction in Bangkok: the impact of hospital ownership and patient payment status.

INTRODUCTION: Patient satisfaction with care received is an important dimension of evaluation that is examined only rarely in developing countries. Evidence about how satisfaction differs according to type of provider or patient payment status is extremely limited. OBJECTIVE: To (i) compare patient perceptions of quality of inpatient and outpatient care in hospitals of different ownership and (ii) explore how patient payment status affected patient perception of quality. METHODS: Inpatient and outpatient satisfaction surveys were implemented in nine purposively selected hospitals: three public, three private for-profit and three private non-profit. RESULTS: Clear and significant differences emerged in patient satisfaction between groups of hospitals with different ownership. Non-profit hospitals were most highly rated for both inpatient and outpatient care. For inpatient care public hospitals had higher levels of satisfaction amongst clientele than private for-profit hospitals. For example 76% of inpatients at public hospitals said they would recommend the facility to others compared with 59% of inpatients at private for-profit hospitals. This pattern was reversed for outpatient care, where public hospitals received lower ratings than private for-profit ones. Patients under the Social Security Scheme, who are paid for on a capitation basis, consistently gave lower ratings to certain aspects of outpatient care than other patients. For inpatient care, patterns by payment status were inconsistent and insignificant. CONCLUSIONS: The survey confirms, to some extent, the stereotypes about quality of care in hospitals of different ownership. The results on payment status are intriguing but warrant further research.

Adolescent↗
PubMed1999

Parents' judgements about young children's problems: why mothers and fathers might disagree yet still predict later outcomes.

Correlates of parents' ratings of behavioural problems were explored in a sample of 93 British families, in which mothers and fathers rated their children at the time of the fourth birthday on the Achenbach Child Behavior Checklist. As in other samples, there was moderate convergence in mothers' and fathers' total problem scores, but also signs that they were reporting different sorts of problems linked to different influences. The father's rating was primarily associated with the child's cognitive ability. The mother's rating was primarily affected by her own mental state and view of her marriage. The father's but not the mother's rating provided unique information that predicted teachers' reports of the children's problems 7 years later. In general, parents' ratings of preschool children's problems reflect particular informants' perspectives on family life.

Affective Symptoms↗
PubMed1998

US EPA's IRIS pilot program: establishing IRIS as a centralized, peer-reviewed data base with agency consensus. Integrated Risk Information System.

The US EPA's Integrated Risk Information System (IRIS) contains Agency consensus scientific positions and quantitative values on cancer and noncancer health effects that may result from lifetime oral or inhalation exposure to specific chemical substances in the environment. Combined with specific exposure assessment information, the summary health information in IRIS may be used as a source in evaluating potential public health risks from environmental contaminants. IRIS is available to the public via EPA's Internet server at http://www.epa.gov/iris. Originally developed for internal EPA use, IRIS usage has broadened since being made publicly available in 1988 to include the private and public sectors nationally and internationally. Up to 1995, IRIS summaries were generated from within various EPA Offices and Regions and reviewed by Agency Workgroups, one for cancer and one for noncancer endpoints, before entry onto IRIS. In response to the increasing usage and recognition of IRIS and suggestions for improvement, an IRIS Pilot program was initiated in 1995. The purpose of the Pilot was 3-fold: To improve efficiency in getting information on to IRIS; to improve documentation for the positions reported in IRIS summaries, including applying new methodologies and guidance; and to improve opportunity for public input including external peer review. A new infrastructure was put in place, consisting of a cross-Agency team of 'Chemical Managers', a Pilot Program Manager, and a set of Agency 'Consensus Reviewers'. Cancer and noncancer assessments were prepared in an integrated fashion for Pilot chemical substances, documented in 'Toxicological Reviews' and derivative IRIS summaries. Public input was emphasized via an initial data call and rigorous external peer review. A final step was Agency-wide consensus review by senior staff scientists representing EPA's Offices and Regions. EPA's experience with the Pilot is forming the basis for designing operational aspects of the long-term IRIS program.

Benchmarking↗
PubMed1998

The Gambian National Impregnated Bednet Programme: costs, consequences and net cost-effectiveness.

Clinical trials have indicated that treating mosquito nets with insecticide could be a potentially cost-effective method of preventing malaria. As malaria is one of the most common causes of death in children under five in developing countries, there has been substantial interest in whether such findings can be replicated for a country's control programme in practice. The cost-effectiveness of the Gambian National Insecticide-impregnated Bednet Programme (NIBP), from the viewpoint of providers (government and non-governmental agencies) and the community, has been calculated. Information was collected from existing records, interviews with NIBP personnel, observation and household surveys. Information is provided on the resource use consequences of the NIBP in terms of reduced expenditure on anti-malaria preventive measures, treatment in government health services, household financed treatment and "charity" (burial, funeral and mourning activities), as well as cash income lost as a result of child death. The annual implementation cost of the NIBP was D757,875 (US$91,864), of which 86% was recurrent cost. The estimated number of death averted was 40.56. The net implementation cost-effectiveness ratio per death averted and discounted life years gained were D3884 (US$471) and D260 (US$31.5), respectively. Adding the cost of all mosquito nets would increase the cost-effectiveness ratios by over five times, which is an important consideration for countries with a lower coverage of mosquito nets per capita. It is concluded that insecticide-impregnated mosquito nets are one of the more efficient ways of reducing deaths in children under 10 years in rural Gambia.

Bedding and Linens↗
PubMed1998

The cost of treating paediatric malaria admissions and the potential impact of insecticide-treated mosquito nets on hospital expenditure.

OBJECTIVE: To calculate the costs at Kilifi District Hospital (KDH) and Malindi Sub-district Hospital (MSH) of treating paediatric malaria admissions including three common presentations of severe paediatric malaria, i.e. cerebral malaria, severe malaria anaemia and malaria-associated seizures; and to estimate the implications for hospital expenditure of a reduction in paediatric malaria admissions. METHODS: Patient data were obtained from hospital records. All costs were allocated to departments that provided direct patient care by a four-stage step-down procedure. Laboratory and drug costs of treating paediatric malaria admissions were separately identified. RESULT: Unit recurrent costs per admission in KDH ranged from US $57 for 'other' paediatric malaria to US $105 for cerebral malaria, and in MSH from US $33 to US $44 for the same categories. The annual recurrent cost of treating all paediatric malaria admissions to KDH prior to the trial was estimated at US $78 900. Adjusting for preintervention differences in malaria admission rates and age between intervention and control areas, the ITBN trial found a 41% reduction in paediatric malaria admissions. The reduction in admissions resulted in an estimated saving of US $6240 in the cost of treating paediatric malaria admissions from the intervention area. CONCLUSION: There would be a substantial reduction in costs of treating paediatric malaria admissions if the intervention were introduced in the whole catchment area of the hospital. Actual savings would depend on the proportion of potential savings that can in practice be realised, and on the effectiveness of the intervention when routinely implemented.

Anemia↗
PubMed1998

Operational research on the economics of insecticide-treated mosquito nets: lessons of experience.

Over the last 10 years or so, awareness has grown of the importance of including an economic component in studies evaluating the potential of new interventions against the main tropical diseases such as malaria. There has been a tendency to regard this as a simple addition to carry out, not requiring specialised knowledge or skills, or substantial time and resources. One consequence has been the rather slow development of knowledge on economic aspects, with a literature that is both small and of uneven quality. This review draws on the experience of supporting the addition of an economic component to the large African trials of the impact of insecticide-treated mosquito nets, as well as on a broader knowledge of the literature on the economics of malaria, to discuss what type of economic information can be useful and what questions it can be used to answer, how the information can be obtained, what pitfalls are likely to be encountered in interpretation, and what needs to be done to improve the quantity and quality of studies.

Bedding and Linens↗
PubMed1998

To contract or not to contract? Issues for low and middle income countries.

Many low and middle income countries have inherited publicly funded and provided health services, often operating at relatively low levels of technical efficiency. Changing ideas about the management of the public sector, in particular stemming from new public management theory, are spreading to these countries, whether directly or via the recommendations of multilateral and bilateral aid agencies. Pronouncements of agencies such as the World Bank imply that competitive contracting with the private sector is likely to improve the efficiency of services provision. However, very little evidence is available on whether this is likely to be the case, and in what circumstances delivery of services through contracts with the private sector is likely to be preferable to direct provision by the public sector. This paper draws on evidence from five country case-studies of contractual arrangements, in Bombay, Papua New Guinea, South Africa, Thailand and Zimbabwe, done through collaborative research between the LSHTM Health Economics and Financing Programme and local researchers in each country. A common evaluative framework was applied in each country to selected, existing contractual arrangements. Services provided under contract and evaluated included catering, cleaning, security, diagnostic services and whole hospitals. Information is presented on the design of contracts, the process of agreeing contracts including the extent of competition, and the monitoring of contract performance. A variety of evidence, including information on the relative cost and quality of contracted out versus directly provided services in the case of South Africa, Thailand, and Bombay, is used to explore whether or not contracting out to the private sector represented a preferable means of service provision. This analysis, together with information on the capacity of the agency letting the contract, and on the wider environment including the level of development of the private sector, is used to identify which aspects of the contracting process and the context in which it takes place are important in influencing whether or not contracting with the private sector is a desirable means of service provision.

Contract Services↗
PubMed1998

Researching the public/private mix in health care in a Thai urban area: methodological approaches.

The private health sector has been growing rapidly in many low and middle income countries, yet not enough is known about its sources of finance or characteristics of its users. Moreover, health care reform measures are leading to alterations in the mix of public and private finance and provision, increasing further the need for information. This paper presents and evaluates some research methods which can be used to collect information relevant to considering policies on the public/private mix. They comprise a household survey, a health diary and interview survey, a bed census, and a health resource survey. Each method is described as it was used in a study in a large urban setting in Thailand, and strengths and weaknesses of the methods are identified. The use of data to estimate the shares of public and private finance and provision, and particularly private sources of finance of public hospitals and public sources of finance for private hospitals, is demonstrated. Policy issues highlighted by the data are identified.

Health Care Reform↗
PubMed1998

Health policy reforms and their impact on the practice of tropical medicine.

This paper addresses the consequences of reforming health policies on the practice of tropical medicine. It briefly reviews the historical development of health systems in poor, tropical countries before summarising current trends in the reform of financing and management. Reforms considered include decentralising management, broadening choices in health financing, particularly introducing user fees, introducing 'managed competition' principles, and working with the private sector. Experiences in different countries are used to highlight some of the dangers inherent in current reform trends. It is suggested that while monopolistic and centralised systems of public provision are unlikely to come back into fashion, much can be done to build on the more positive aspects of current reforms and to minimise their undesirable side effects. Key issues are developing mechanisms that ensure that services are responsive to users, avoiding polarisation of services between rich and poor, and improving systems of regulation, supervision and monitoring.

Cost-Benefit Analysis↗
PubMed1998

Can a change in screening and prescribing practice reduce the risk of venous thromboembolism in women taking the combined oral contraceptive pill?

The risk of Venous thromboembolism (VTE) associated with low dose combined oral contraceptive pills (COCs) is low at between 15 and 30 cases per 100 000 women years of use. Screening the total population or even those women with a family history of VTE in a first degree relative is unlikely to have a major impact on the number of cases of VTE associated with COC. Women with a known family history of an inherited thrombophilia should have this defect excluded before taking COCs. Women with a known thrombophilia or a personal history of VTE should consider alternative methods of contraception to the COC.

Adult↗
PubMed1997

Adolescent friendships mediating childhood adversity and adult outcome.

This interview-based study compares the friendships of 50 girls, aged 15-16, identified on the basis of their childhood experiences as being at-risk for difficulties in early adult partnerships, with the friendships of 50 girls of the same age from an inner-city school. Key differences in the features of both romantic and non-romantic adolescent friendships between the two groups of girls give a clearer understanding of the processes linking childhood adversity and poor adult outcome.

Adolescent↗