Cross border health care in Europe.
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Delivery of Health Care↗
Biomedical subjects
M McKee
Publications and source records attributed to M McKee.
Global epidemic of cardiovascular disease.
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Cardiovascular Diseases↗
What has contributed to the change in life expectancy in Italy between 1980 and 1992?
Life expectancy at birth in southern Europe is known to be greater than expected in comparison with levels of economic development. This has been attributed to the 'Mediterranean diet'. There are, however, concerns that this comparative advantage is being lost. This paper examines the factors underlying changing life expectancy in Italy since 1980. The subjects of this analysis are obtained from data on all deaths in Italy between 1980 and 1992. Change in age specific death rates is calculated from selected causes and, using the method developed by Pollard, the contribution of deaths from different causes and at different ages to changing life expectancy at birth is estimated. Between 1980 and 1992, life expectancy at birth increased by 2.70 years for men and 2.75 years for women. Death rates have fallen among children and those over 40. In contrast, death rates have increased among men aged between 20 and 39 and have increased very slightly among women aged 25-29. Falling death rates from ischaemic heart disease are continuing to contribute to increasing life expectancy. Death rates from lung and breast cancer are rising among women but are compensated for by falling death rates from other cancers. Among men, falling death rates from cancer at younger ages are being offset by increases at older ages. The rising death rate among younger men is almost entirely due to AIDS, with accidents also making a small contribution. Life expectancy in Italy has improved throughout the 1980s, largely driven by falling death rates from cardiovascular diseases. Here are, however, some worrying trends, most notably the rising death rate among young men, due almost entirely to AIDS. The changing pattern of mortality has some similarities with Spain, another Mediterranean country, but there are also important differences.
Acquired Immunodeficiency Syndrome↗
Why is the death rate from lung cancer falling in the Russian Federation?
Age standardised death rates (European standard population) from lung cancer in the Russian Federation, have been rising since at least 1965, levelled out in the late 1980s and have subsequently decreased. The reasons for this decline are not apparent. This study seeks to identify the reasons for the decline in mortality from lung cancer in the Russian Federation in the 1990s. Changes in age-specific mortality from lung cancer in the Russian Federation between 1990 are described and age-cohort analysis, based on age-specific death rates for lung cancer is undertaken for the period 1965 to 1995. As other work has shown that any recent deterioration in coding of cause of death has been confined largely to the elderly, this suggests that the trend is not a coding artefact. Age-period-cohort analysis demonstrates the existence of a marked birth cohort effect, with two major peaks corresponding to those born around 1926 and 1938. These groups would have reached their early teens during the second world war and the period immediately after the death of Stalin, respectively. The present downward trend in death rates from lung cancer in the Russian Federation is partly due to a cohort effect and it is expected that this will soon reverse, with a second peak occurring in about 2003.
Adolescent↗
Alcohol consumption in a national sample of the Russian population.
AIMS: Alcohol has been suggested as an important determinant of mortality in Russia but survey data on individuals' alcohol consumption in Russia are sparse. We have analysed the levels and distribution of alcohol consumption in a national sample of the Russian population. DESIGN: Cross-sectional survey. PARTICIPANTS: A multi-stage random sample of men and women of the Russian Federation (N = 1599, response rate 66%). MEASUREMENTS: Data on frequency of drinking alcohol and the average amount consumed at one occasion were collected in an interview. Information was also collected on smoking, self-rated health and a broad range of socio-economic factors and political attitudes. FINDINGS: Nine per cent of men and 35% of women reported that they never drink alcohol; 10% of men and 2% women drink several times a week; 44% of men and 6% of women reported that they drink an equivalent of 25 cl of vodka or more at one occasion and 31% of men and 3% of women would do so at least once a month (25 cl of vodka contains 78.5 g of absolute alcohol). There were differences in alcohol consumption between geographical areas. Material deprivation was not related to alcohol consumption. Among men, smokers, unmarried, unemployed and men reporting poor health consumed more alcohol; women with higher education, widows, non-smoking and with worse health consumed less alcohol. Variables related to reaction to economic and political changes, rating of family economic situation general satisfaction or political preferences were not related to alcohol consumption. CONCLUSIONS: While the overall levels of alcohol consumption appeared low, possibly due to under-reporting, the proportion of men who can be considered as "binge drinkers" was relatively high. The absence of sizable socio-economic differences suggest that drinking may be spread relatively uniformly in Russia, especially among males. Alcohol consumption seems unrelated to individuals' perception of the recent societal changes.
Adolescent↗
The effect of severity of unilateral vestibular dysfunction on symptoms, disabilities and handicap in vertiginous patients.
This study compares the symptoms, disabilities and handicap, as assessed by means of a questionnaire, in two groups of patients with a unilateral peripheral vestibular disorder: those with a total canal paresis and those with a partial canal paresis, as judged by the duration parameter using the Fitzgerald Hallpike caloric test in the absence of optic fixation. The results of the study indicate that the severity of dizziness, the Dizziness Index (severity x frequency) and the overall level of disabilities related to visual vertigo are less severe in unilateral profound or total loss of vestibular function than in unilateral mild vestibular loss.
Case-Control Studies↗
Cancer mortality in Russia and Ukraine: validity, competing risks and cohort effects.
BACKGROUND: The dramatic increase in mortality in Russia and Ukraine in the late 1980s and 1990s has been due to increases in certain causes of death, particularly cardiovascular disease and accidents and violence. In contrast, there has been a slight fall in mortality from cancer. METHODS: This paper presents an analysis of trends and patterns in cancer mortality and examines four possible explanations for its recent fall: changes in data collection; cohort effects; competing mortality from other causes of death; and improvements in health care. RESULTS: All contribute to some extent to the observed changes, with each affecting predominantly different age groups. There is evidence of a significant underrecording of cancer deaths among the elderly especially in rural areas and of significant changes in coding practices in the early 1990s. Competing mortality from cardiovascular diseases and accidents can explain some reduction in male deaths from cancer in middle age. Birth cohort effects can explain some reduction among males after early middle age and among females at all ages. The impact of changes in health care are more difficult to identify with certainty but there is evidence of reduced deaths from childhood leukaemia. IMPLICATIONS: Recent changes in mortality in Russia are complex and their understanding will require a multidisciplinary approach embracing demography, epidemiology and health services research.
Adolescent↗
Surgical outpatient clinics: are we allowing enough time?
BACKGROUND: Performance management initiatives, such as the UK's Patient's Charter, are creating pressure for patients to be seen earlier at out patient clinics, thus increasing clinic workloads. There is, however, little information about whether this can be absorbed, either by utilizing spare capacity or by more efficient use of time, or whether it is likely to affect patient care adversely. METHODS: Nine surgical clinics, run by four general surgeons, in an English district general hospital were studied during a typical week. Clinic schedules and numbers invited to attend were extracted from clinic records. An observer recorded the actual time each patient spent with the surgeon to the nearest 5 seconds. Scheduled and actual times of commencement and completion of clinics were also recorded. RESULTS: The number of patients booked to attend each clinic varied from 11 to 82 (mean 37). The median consultation for new patients was 4.3 minutes and for follow-up patients it was 3 minutes. Consultants spent a median 2.7 minutes with patients whereas junior staff spent 4.2 minutes. These aggregate results conceal considerable variation between surgeons, even though the scheduled time available was similar. The median time spent with new patients by one consultant was 1.3 minutes and by another 13.1 minutes. Seven of the nine clinics overran their scheduled time (by up to 55 minutes). All doctors, with one exception, arrived late for the clinics (range 10 minutes early to 30 minutes late). The first patient was invariably seen after the scheduled starting time for the clinic (mean 17 minutes, range 5-50 minutes) and the median interval between a doctor arriving and seeing their first patient was 10.6 minutes. Overall, only 50% of the time spent by doctors at the clinics was with patients. IMPLICATIONS: The amount of time spent by patients with surgeons is already so short as to cause concern about both the appropriateness and value of consultations. It is unreasonable to increase workload further. There is a clear need for outpatient clinics to be managed, with regular examination of what is taking place and how long it takes. Only then will it be possible to tailor schedules to the actual requirements of the service.
Appointments and Schedules↗
'Failure to rescue' as a measure of quality of hospital care: the limitations of secondary diagnosis coding in English hospital data.
Although it is widely recognized that quality of care varies between hospitals, a robust and valid measure of outcome that can be used in comparisons has proven elusive. One measure that has recently been proposed by US researchers is the 'failure to rescue' (FTR) rate. This is based on the assumption that, whereas complications may reflect both patient severity and health care factors, the ability to save patients once complications arise is much more closely related to the quality of health care. We describe an evaluation of FTR in a national sample of English hospitals using hospital episode data. We found that the rate of secondary diagnosis recording in England is about one-tenth that in the United States. The FTR rate would be highly sensitive to variations in the completeness of coding of secondary diagnoses. Unless coding is of uniformly high quality, any attempt to compare severity adjusted outcomes will be potentially unreliable.
Adolescent↗
Patterns of smoking in the Baltic Republics.
BACKGROUND: Tobacco is a leading cause of avoidable death in the Baltic Republics but there is, as yet, relatively little information in the public domain on who is smoking and how this is changing. This information is important for those seeking to develop effective policies to tackle this issue. OBJECTIVE: To determine the pattern of smoking in Estonia, Latvia, and Lithuania. METHODS: Analysis of data on patterns of tobacco consumption from representative surveys of approximately 3000 adults aged under 65 in each country undertaken in 1997. RESULTS: The prevalence of smoking among men is 53.9%, 56.0%, and 53.2% respectively in Estonia, Latvia, and Lithuania. The corresponding figures for women are 24.1%, 10.9%, and 7.6%. For both sexes, current smoking rates are consistently lowest in the age group 50 to 64 and highest in the age group 35 to 49. Education and income are determinants of smoking rates among men but much less so among women. Russian men are more likely to smoke than are men from the majority group in each country. Smoking rates among women are much lower in rural than in urban areas of Latvia and Lithuania but this is not so in Estonia. CONCLUSIONS: Smoking rates among men in the Baltic Republics are already very high. Among women, they still vary considerably. Each country has implemented some measures to reduce smoking. These seem to have been especially effective in Lithuania but, overall, much more action is needed.
Adult↗
Effect of acidification on the location of H+-ATPase in cultured inner medullary collecting duct cells.
In previous studies, our laboratory has utilized a cell line derived from the rat inner medullary collecting duct (IMCD) as a model system for mammalian renal epithelial cell acid secretion. We have provided evidence, from a physiological perspective, that acute cellular acidification stimulates apical exocytosis and elicits a rapid increase in proton secretion that is mediated by an H+-ATPase. The purpose of these experiments was to examine the effect of acute cellular acidification on the distribution of the vacuolar H+-ATPase in IMCD cells in vitro. We utilized the 31-kDa subunit of the H+-ATPase as a marker of the complete enzyme. The distribution of this subunit of the H+-ATPase was evaluated by immunohistochemical techniques (confocal and electron microscopy), and we found that there is a redistribution of these pumps from vesicles to the apical membrane. Immunoblot evaluation of isolated apical membrane revealed a 237 +/- 34% (P < 0.05, n = 9) increase in the 31-kDa subunit present in the membrane fraction 20 min after the induction of cellular acidification. Thus our results demonstrate the presence of this pump subunit in the IMCD cell line in vitro and that cell acidification regulates the shuttling of cytosolic vesicles containing the 31-kDa subunit into the apical membrane.
Acids↗
Threats to applicability of randomised trials: exclusions and selective participation.
BACKGROUND: Although the randomised controlled trial (RCT) is regarded as the 'gold standard' in terms of evaluating the effectiveness of interventions, it is susceptible to challenges to its external validity if those participating are unrepresentative of the reference population for whom the intervention in question is intended. In the past, reporting on numbers and types of potential subjects that have been excluded by design, and centres, clinicians or patients that have elected not to participate, has generally been poor, and the threat to inference posed by possible selection bias is unclear. METHODS: A systematic review was undertaken, based largely on MEDLINE and EMBASE with follow-up of cited references, to assess the extent, nature and importance of excluding potential subjects or the unwillingness of particular centres, clinicians or patients to participate. RESULTS: RCTs vary widely in the extent to which potential future recipients of treatment are included. The reasons cited for excluding certain categories of patient may be medical or scientific. Medical reasons include a high risk of adverse effects and the belief that benefit will be relatively small or absent (or has already been established) in the groups in question. Scientific reasons include more precise estimates of treatment effect because of a relatively homogeneous sample and the reduction of potential bias by excluding those individuals most likely to be lost to follow-up. Many RCTs have blanket exclusions, such as the elderly, women and ethnic minorities, but reasons for these exclusions are seldom given. Evaluative research is undertaken predominantly in university or teaching centres. Non-randomised studies are more likely than RCTs to include non-teaching centres. The effect of patient non-participation appears to depend on whether the RCT is concerned with treatment of an existing condition or with disease prevention. Participants in treatment trials tend to be more severely ill than those who do not participate. In contrast, those who participate in prevention trials are more likely to have adopted a healthy lifestyle than those who decline. Most evaluative studies fail to document adequately the characteristics of those who, while eligible, do not participate. However, subjects included in RCTs (i.e. eligible and participating) tend to have a different prognosis than patients identified from clinical databases. CONCLUSIONS: Narrow inclusion criteria may offer benefits such as increased precision and reduced loss to follow-up, but there are important disadvantages, such as uncertainty about extrapolation of results, which may result in denial of effective treatment to groups who might benefit, and delay in obtaining definitive results because of reduced recruitment rate. Selective participation by teaching centres and sicker patients in treatment RCTs may exaggerate the measured treatment effect. Prevention trials, on the other hand, may underestimate effects as participants have less capacity to benefit.
Australia↗
Consensus development methods: a review of best practice in creating clinical guidelines.
BACKGROUND: Although there is debate about the appropriate place of guidelines in clinical practice, guidelines can be seen as one way of assisting clinicians in decision-making. Given the likely diversity of opinion that any group of people may display when considering a topic, methods are needed for organising subjective judgements. Three principal methods (Delphi, nominal group technique, consensus development conference) exist which share the common objective of synthesising judgements when a state of uncertainty exists. OBJECTIVES: To identify the factors that shape and influence the clinical guidelines that emerge from consensus development methods and to make recommendations about best practice in the use of such methods. METHODS: Five electronic databases were searched: Medline (1966-1996), PsychLIT (1974-1996), Social Science Citation Index (1990-1996), ABI Inform and Sociofile. From the searches and reference lists of articles a total of 177 empirical and review articles were selected for review. RESULTS: The output from consensus development methods may be affected by: the way the task is set (choice of cues, recognition of contextual cues, the focus of the task, the comprehensiveness of the scenarios); the selection of participants (choice of individuals, degree of homogeneity of the group, their background, their number); the selection and presentation of scientific information (format, extent to which its quality and content is assessed); the way any interaction is structured (number of rating rounds, ensuring equitable participation, physical environment for meetings); and the method of synthesising individual judgements (definition of agreement, rules governing outliers, method of mathematical aggregation). CONCLUSIONS: Although a considerable amount of research has been carried out, many aspects have not been investigated sufficiently. For the time being at least, advice on those aspects has, therefore, to be based on the user's own commonsense and the experience of those who have used or participated in these methods. Even in the long term, some aspects will not be amenable to scientific study. Meanwhile, adherence to best practice will enhance the validity, reliability and impact of the clinical guidelines produced.
Benchmarking↗
For debate--Does health care save lives?
The contribution of health care to the health of a population has long been controversial. In the 1970s, McKeown and Illich argued that health care had made little contribution to population health and may actually be damaging it. There is, however, a growing body of evidence that health care now has a demonstrable effect on health at a population level, albeit subject to certain methodological limitations that affect the precision of the estimates of scale. In particular, there is emerging evidence that reduced access to high quality medical care may contribute to the east-west gap in mortality in Europe and to social inequalities in mortality in some industrialised countries. These findings apply both to overall measures of mortality amenable to medical care as well as to death rates in particular age groups and from particular conditions, where the association between policy and outcome tends to be clearer. These findings have implications for those who seek to promote health at population or individual level. Primarily, there needs to be a stronger link between public health and health care, with those in public health recognising that health care can make a difference and those in health care recognising the right of public health to challenge what they do.
Health Policy↗
On editorial freedom: implications of the JAMA affair.
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American Medical Association↗
[European public health professionals express ten priorities for the European Union...to be followed].
Even if the European Union acquired explicit competencies in public health with the Maastricht and Amsterdam Treaties (articles 129 and 152), public health professionals still have not had their word in the definition of public health priorities. Yet it is they, whatever their mission, who must take into consideration the new constraints imposed by Community directives. The French Society for Public Health (FSPH) took the initiative of running a project, financed by the European Commission, aiming to shed light on some of the public health problems considered priority in the 15 member states, and to provide suggestions for facing them. The FSPH adopted a resolutely participative and pragmatic process. At each step (definition of priorities and compiling arguments), the intention of the SFPH was more to allow different, even diverging, points of view to be expressed, than to aim for a hypothetical representativeness. The undertaken themes are the social gradients in health, alcohol, illicit drugs, tobacco, surveillance of health issues, quality of care, older persons, mental health, the environment, nutrition and food security. This work marks the wish of the FSPH for international openness toward Europe. The FSPH hopes that this work becomes a platform for the development of a reinforced dialogue between public health professionals and European decision makers.
Attitude of Health Personnel↗
Economic change, crime, and mortality crisis in Russia: regional analysis.
OBJECTIVE: To identify which aspects of socioeconomic change were associated with the steep decline in life expectancy in Russia between 1990 and 1994. DESIGN: Regression analysis of regional data, with percentage fall in male life expectancy as dependent variable and a range of socioeconomic measures reflecting transition, change in income, inequity, and social cohesion as independent variables. Determination of contribution of deaths from major causes and in each age group to changes in both male and female life expectancy at birth in regions with the smallest and largest declines. SETTING: Regions (oblasts) of European Russia (excluding Siberia and those in the Caucasus affected by the Chechen war). SUBJECTS: The population of European Russia. RESULTS: The fall in life expectancy at birth varied widely between regions, with declines for men and women highly correlated. The regions with the largest falls were predominantly urban, with high rates of labour turnover, large increases in recorded crime, and a higher average but unequal distribution of household income. For both men and women increasing rates of death between the ages of 30 and 60 years accounted for most of the fall in life expectancy, with the greatest contributions being from conditions directly or indirectly associated with heavy alcohol consumption. CONCLUSIONS: The decline in life expectancy in Russia in the 1990s cannot be attributed simply to impoverishment. Instead, the impact of social and economic transition, exacerbated by a lack of social cohesion, seems to have played a major part. The evidence that alcohol is an important proximate cause of premature death in Russia is strengthened.
Adolescent↗
Does the WHO have a role in Europe?. There is more to "Europe" than you might think.
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Delivery of Health Care↗