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PubMed2005

Delivering pneumococcal vaccine to a high risk population: the Navajo experience.

High rates of preventable diseases such as pneumococcal disease occur among the Navajo despite their universal health insurance through the Indian Health Service. The objective of this study was to determine the proportion of Navajo adults vaccinated with pneumococcal polysaccharide vaccine and to examine key features of vaccination programs of the Navajo Indian Health Service. For this cross-sectional study, medical charts of Navajo patients with vaccine indications were randomly selected and reviewed to determine who had been vaccinated as of January 1, 1999. Among 480 Navajo>or=65 years old, 73% were vaccinated (95% confidence interval [CI]: 69%-77%). Among 111 Navajo 18-64 years old with vaccine indications, 54% were vaccinated (95% CI: 45% -63%). Vaccination programs utilized extensive public health nursing, home visits, standing orders, and "express lane" clinics. In spite of excellent delivery systems and universal healthcare, the proportion of Navajo persons vaccinated was still below the goals for Healthy People 2010 of having 90% of persons>or=65 years old vaccinated and 60% of high-risk persons 18-64 years old vaccinated.

Adolescent↗
PubMed1995

California physicians' willingness to care for the poor.

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.

Adult↗
PubMed2003

Determinants of health care use by children in rural western North Carolina: results from the Mountain Accessibility Project.

OBJECTIVE: To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States. METHODS: Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods. RESULTS: Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >40 000 dollars per year had 76% more visits than those with incomes <20 000 dollars per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >40 000 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group. CONCLUSIONS: This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child's pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation.

Child↗
PubMed1995

Arnold Aberman, MD.

When the United States embarked on its effort to provide universal health insurance, the Canadian Medicare System was cited as a possible model for American health care. Often touted as an example of low-cost, high quality medicine, the Canadian system has mirrored the problems of health care across its southern border. With rocketing health care expenditures and financing having largely been decentralized to the individual provinces, local officials have struggled to cut costs and services. A central focus of these efforts has been a move to decrease the numbers of physicians, most notably a 10% decrease in medical school class size in 1993. While some Western provinces have experimented with the privatization of health care, the Canadian system still remains the epitome of government operated fee-for-service medicine. Given the likelihood of dramatic change in the American Medicare system, Canadian academic centers offer a unique perspective on the impact of capitation, evolving relationships with government payors, and the flip side of market oriented reforms. At the helm of one of Canada's largest schools is Arnold Aberman, MD, dean of the University of Toronto Faculty of Medicine. Born in Montreal, Quebec, Aberman received his MD from McGill University, but then did his residency both in Canada and the US, followed by a pulmonary fellowship at Albert Einstein College of Medicine and the Cardiovascular Research Institute of the University of California, San Francisco. Interviewed at his office in Toronto, Aberman reflected on the trials and tribulations confronting medicine on both sides of the 48th parallel.

Canada↗
PubMed1999

Compensation for birth-related injury: no-fault programs compared with tort system.

OBJECTIVE: To compare compensation systems for birth-related injuries. DESIGN: Retrospective cohort study. SETTING: Florida. PARTICIPANTS: Parents of children with birth-related injuries who filed claims that closed before August 1, 1995, with Florida's no-fault program (Neurological Injury Compensation Act [NICA]) or who filed tort claims that closed from January 1, 1986, to August 1, 1995. MAIN OUTCOME MEASURES: Compensation for medical and income losses due to birth-related injuries. RESULTS: Families who received tort settlements were overcompensated for the injury, considering all sources of compensation. By contrast, NICA recipients broke even. Those who did not receive tort or NICA compensation lost nearly $75000 in the first 5 years following the birth. In the subsample of families of children with cerebral palsy, overcompensation by tort claim was even greater, whereas NICA recipients were undercompensated. The cost of care for cerebral palsy in both groups was the same. The difference between tort and NICA compensation levels was attributable to payment for income loss. Overall, NICA recipients were satisfied with compensation received. CONCLUSIONS: Medical expenses were adequately covered under NICA, but not income loss. A universal health insurance program for children would not cover income losses. Similar costs incurred in NICA and tort systems suggests no rationing of care by NICA. Finally, absent some sort of targeted compensation, the losses experienced by families of children with birth-related injuries were substantial.

Adult↗
PubMed1998

Association between licensing examination scores and resource use and quality of care in primary care practice.

CONTEXT: Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice. OBJECTIVE: To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice. DESIGN: Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice. SETTING: The Quebec health care system. PARTICIPANTS: A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Quebec. MAIN OUTCOME MEASURES: All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population. RESULTS: Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%) were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P = .005), prescribed to elderly patients fewer inappropriate medications (-2.7/1000 patients per SD increase in score; 95% CI, -4.8 to -0.7; P=.009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P= .03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P = .02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening. CONCLUSIONS: Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

Adult↗
PubMed1998

Association of inhaled corticosteroid use with cataract extraction in elderly patients.

CONTEXT: The use of systemic corticosteroids is a known risk factor for the development of cataracts. OBJECTIVE: To determine whether treatment with inhaled corticosteroids is associated with cataract extraction in the elderly. DESIGN: Case-control study. SETTING: Quebec universal health insurance program for all elderly (provincial health insurance plan database [RAMQ database]). PATIENTS: RAMQ enrollees 70 years and older. The 3677 cases were patients with a cataract extraction between 1992 and 1994. The 21868 controls were randomly selected from patients who did not have a diagnosis of cataract and matched to cases on the index date of the case. MAIN OUTCOME MEASURES: Odds ratio of cataract extraction in patients with prolonged cumulative exposure to inhaled corticosteroids compared with nonusers. RESULTS: Excluding patients with systemic steroid treatment and after adjusting for age, sex, diabetes, systemic hypertension, glaucoma, ophthalmic steroids, and the number of physician claims for services, use of inhaled corticosteroids for more than 3 years was associated with undergoing cataract extraction (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.53-6.13). For high average daily doses of beclomethasone or budesonide (>1 mg), the OR was elevated after more than 2 years of treatment (OR, 3.40; 95% CI, 1.49-7.76), whereas for low to medium doses (< or =1 mg) of these drugs, the OR was 1.63 (95% CI, 0.85-3.13) after 2 years. CONCLUSION: Prolonged administration of high doses of inhaled corticosteroids increases the likelihood of undergoing cataract extraction in elderly patients. Further studies are needed to investigate the risk of developing cataracts for low to medium doses over longer periods.

Administration, Inhalation↗
PubMed2001

Long-term MI outcomes at hospitals with or without on-site revascularization.

CONTEXT: Many studies have found that patients with acute myocardial infarction (AMI) who are admitted to hospitals with on-site revascularization facilities have higher rates of invasive cardiac procedures and better outcomes than patients in hospitals without such facilities. Whether such differences are due to invasive procedure rates alone or to other patient, physician, and hospital characteristics is unknown. OBJECTIVE: To determine whether invasive procedural rate variations alone account for outcome differences in patients with AMI admitted to hospitals with or without on-site revascularization facilities. DESIGN: Retrospective, observational cohort study using linked population-based administrative data from a universal health insurance system. SETTING: One hundred ninety acute care hospitals in Ontario, 9 of which offered invasive procedures. PATIENTS: A total of 25 697 patients hospitalized with AMI between April 1, 1992, and December 31, 1993, of whom 2832 (11%) were in invasive hospitals. MAIN OUTCOME MEASURES: Mortality, recurrent cardiac hospitalizations, and emergency department visits in the 5 years following the index admission, adjusted for patient age, sex, socioeconomic status, illness severity, and index revascularization procedures; attending physician specialty; and hospital volume, teaching status, and geographical proximity to invasive-procedure centers and compared by hospital type. RESULTS: Patients admitted to invasive-procedure hospitals were much more likely to undergo revascularization (11.4% vs 3.2% at other hospitals; P<.001). However, many other clinical and process-related factors differed between the 2 groups. Although mortality rates were similar between the 2 institution types, the nonfatal composite 5-year event rate (ie, recurrent cardiac hospitalization and emergency department visits) was lower for patients initially admitted to invasive-procedure hospitals (71.3% vs 80.4%; unadjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.82; P<.001). This advantage persisted after adjustment for sociodemographic and clinical factors and procedure utilization (adjusted OR, 0.68; 95% CI, 0.53-0.89; P<.001). However, the nonfatal outcome advantages of invasive-procedure hospitals were explained by their teaching status (adjusted OR, 0.98; 95% CI, 0.73-1.30; P =.87). CONCLUSIONS: In this sample of patients admitted with AMI, the differing outcomes of apparently similar patients treated in 2 different practice settings were explained by multiple competing factors. Researchers conducting observational studies should be cautious about attributing patient outcome differences to any single factor.

Aged↗
PubMed2000

Associations between community income and cancer incidence in Canada and the United States.

BACKGROUND: Associations between socioeconomic status (SES) and the incidence of cancer have been reported previously in the U.S. Canada has more comprehensive health care and social programs than the U.S. The purpose of this study was to compare the strength of associations between SES and cancer incidence in Canada and the U.S. METHODS: The regions studied were the Canadian province of Ontario and the areas of the U.S. covered by the Surveillance, Epidemiology, and End Results (SEER) program. The populations at risk were defined using the 1991 Canadian Census and the 1990 U.S. Census. The populations of Ontario and of the SEER areas of the U.S. were each divided into deciles on the basis of median household income. Population-based cancer registries were used to identify incident cases. Age-standardized incidence rates for all major groups of malignant diseases were calculated for each SES decile in Ontario and in the U.S. Income-associated incidence gradients observed in Ontario and the U.S. were compared. RESULTS: The incidence of most types of cancer was similar in Ontario and the U.S. In both countries, there were moderately strong, inverse associations between income level and the incidence of carcinomas of the cervix, the head and neck region, the lung, and the gastrointestinal tract. In both Ontario and the U.S., several of these diseases were twice as common in the bottom income decile than they were in the top decile. In contrast, carcinoma of the female breast and carcinoma of the prostate were more common among higher income communities in both countries, but the observed associations were weaker in Ontario. CONCLUSIONS: Despite Canada's universal health insurance and more comprehensive social security system, the association between lower socioeconomic status and the incidence of many common cancers is just as strong in Ontario as it is in the U.S. The mechanisms responsible for these associations require further investigation.

Age Factors↗
PubMed2004

Oral anticoagulants and the risk of osteoporotic fractures among elderly.

PURPOSE: Coumadin-based oral anticoagulants are associated with a decrease in bone mass density, but their role in fracture risk is equivocal. Because the use of oral anticoagulants is prevalent among the elderly, as is the risk and morbidity of osteoporotic fractures, the association between osteoporotic fractures and oral anticoagulants needs to be clarified. METHOD: We conducted a case-control study on a 10% random sample of subjects aged 70 years and older enrolled in the Quebec universal health insurance plan between 1992 and 1994. Incident cases of a first osteoporotic fracture were identified by International Classification of Diseases, Ninth Revision codes. Exposure was defined as one or more prescriptions of oral anticoagulants dispensed before the osteoporotic fracture. Ten controls for each case, matched by age and date of osteoporotic fracture, were identified. RESULTS: Among 1523 cases, 48 (3.2%) were ever exposed to oral anticoagulants; among 15,205 controls, 461 (3.0%) were ever exposed (crude odds ratio: 1.0: 95% confidence interval: 0.7-1.5). These negative results persisted after adjusting for potential confounding variables and stratifying exposure into cumulative dose and treatment duration. CONCLUSIONS: Coumadin-based oral anticoagulants are not significantly associated with osteoporotic fractures among the elderly, providing reassurance for elderly patients on long-term oral anticoagulants.

Administration, Oral↗
PubMed1999

Screening mammography referral rates for women ages 50 to 69 years by recently-licensed family physicians: physician and practice environment correlates.

BACKGROUND: Physician mammography referral remains below optimal levels despite a long-standing recommendation that all women ages 50 to 69 years receive screening mammography every 1 to 2 years. The purpose of this study was to determine physician and practice environment predictors of family physicians' screening mammography referral rates to women ages 50-69 years. METHOD: A cohort of 498 recently-licensed family physicians was followed for 18-months of incipient medical practice. The referral rate was the percentage of new clinically eligible women patients seen in a primary care context who had a screening mammogram ordered by the study physician. Mammograms and independent variables were identified from physician claims to a Canadian universal health insurance agency. The effects of factors in a conceptual framework were assessed using multivariable linear regression. RESULTS: Correlates of higher mammography referral rates were female gender, better general prevention knowledge, the combination of comprehensive inquiry and continuity care, lower patient volume, and lower shared primary care (multivariable model R(2) = 0.47). Factors belonging to practice environment explained more of the observed variance than did physician characteristics. CONCLUSIONS: Mammography referral varies enormously and almost half of the variance is explained by physician characteristics and practice preferences. Higher mammography referral is observed in practices with more comprehensive and continuity care.

Adult↗
PubMed1989

Inequity in health. A case study.

This article presents a particular case of inequity in health, that of two types of Israeli urban settlement: development towns and veteran towns. Inequity in health is demonstrated by the varying levels of resources allocated to each type of community, by the differences in health-care utilization (process), and by the diversity of external factors affecting the two categories of towns. Despite the existence of almost universal health insurance coverage in Israel, it is shown that inhabitants of less privileged development towns are more prone to inequitable health outcomes with respect to the wealthier populations living in veteran towns. This case illustrates an integrated approach to inequity in health, including the health-care system structure, utilization patterns, and the socio-demographic-economic background of different strata.

Adult↗
PubMed1992

Regional variation in VAMC's operative efficiency.

The Department of Veterans Affairs is managed by a global budget regulated by Congress. How effective the VA handles this budget can provide insight into future plans for any form of universal health insurance. Using Date Envelope Analysis (DEA) this study shows that 51 of 158 continental VAMCs operate relatively efficiently. Variation in operative efficiency could be explained by Service Area size and geographic regional location. This finding suggests more active regional planning may improve veteran hospital operative efficiency.

Ambulatory Care↗
PubMedDate not supplied

Repeated users of a psychiatric emergency service in a Canadian general hospital.

The authors of this study examine the demographic and clinical characteristics of repeated users of psychiatric emergency room services in a general hospital. 37.8% of all the patients (913) seen during one year had one or more visits to the emergency room in the six months preceding the index emergency room consultation. Repeaters were more likely than nonrepeaters to be unmarried, self referred and with a history of previous psychiatric treatment for a chronic psychiatric disorder. Factors affecting frequency of use of psychiatric emergency room services among different diagnostic groups were also studied. These results demonstrated the heterogeneity of the needs of the diverse diagnostic groups who over-utilize costly emergency room services. Our findings showed that in a country with universal health insurance, psychiatric emergency services also tend to reflect the gaps in the delivery of health services in the hospital and the community.

Adult↗
PubMed2002

The system of care for the elderly in Thailand: capitalizing from an integrated community-based health system through reform.

Thailand is facing a dramatic challenge of how to ensure good health and quality of life for its rapidly increasing number of elderly citizens. The modern health services system established a century ago has a larger proportion of public providers, but only 35-40% share public spending on health. The health services administration, its infrastructure and health policies underwent a number of reforms resulting in a system that emphasizes community-based comprehensive health services with a multi-sectoral approach to health. There has been remarkable concern over the health and well-being of the elderly for the last two decades, leading to the introduction of specific policies and programs, both in health and social sectors. The health service infrastructure has better coverage compared to social services, with a varying degree of integration between the two depending partly on existing resources and management in each locality. Among many other social services, there are homes for the elderly and income support for the poor elderly. However, health services and institutions for the elderly are not being created separately, but rather by adding new services and programs to the existing comprehensive and integrated system of service delivery. The changing political and socio-economic environment provides a great opportunity to make the health and social services more responsive to the needs of the elderly, now and in the future. Decentralization and the universal health insurance policy of the new government with an emphasis on strong primary care providers will give a great push forward to the presently community-oriented nature of the extensive health service infrastructure.

Aged↗
PubMed1999

Prevalence of diabetes mellitus among workers in Israel: a nation-wide study.

The prevalence of diabetes mellitus in Israel has been described in various populations and ranges from 4.1% to 8.9%. However, the large immigration wave in the late 1980s and early 1990s could have affected the previous estimates. Moreover, data from the United states and other countries report a significant proportion of undiagnosed diabetes. The main purpose of this study was to estimate the prevalence and the ratio of undiagnosed/diagnosed diabetes in a large sample of workers. The study involved interviews, anthropometric measurements at the work site, and blood glucose determinations (casual capillary, fasting, and when necessary, 2 h after a 75-gram oral glucose load). Diabetes and impaired glucose tolerance (IGT) were diagnosed according to WHO criteria. Five thousand four hundred sixteen workers participated in the study. Three hundred ten reported to be known diabetics (5.7%), 35 (0.7%) were diagnosed as diabetic during the survey, and an additional 93 (1.8%) were classified as IGT. The ratio undiagnosed/diagnosed diabetes was therefore 1:10. Extrapolation of these results produced an estimate of diabetes prevalence in Israel of 10% among people over age 40 years. It seems that in the Israeli health care system, based on universal health insurance and easy access to primary care, the proportion of undiagnosed diabetes is lower than that described in other countries.

Adult↗
PubMed1982

The utilization of health services. Sequence of visits to general practitioners.

Multivariate studies of health services utilization have been particularly disappointing. Some of the difficulties might be within the conceptualization of the utilization concept. The purpose of this paper is to suggest that propensity to utilize should be expressed in time sequences and that an explanation should be sought for such sequences, rather than for the total number of times physicians are consulted. Using data from the universal health insurance scheme in Québec, the concept of sequence of visits is illustrated, while variations in utilization patterns are better explained by the sequences of utilization than by age and sex.

Adolescent↗
PubMed1985

Japan's clinic physicians and their behavior.

The paper examines the behavior of the Japanese general practitioner or clinic physician. Clinic physicians in Japan are entrepreneurs who own and operate their own clinics with either no beds or less than 20 beds. They have been the prime providers of Japan's health care, and they are represented by the politically powerful Japan Medical Association. General practitioners are reimbursed basically on the basis of fee-for-service with fees determined by the authority. Japan has universal health insurance. The paper modeled the general practitioner as a maximizer of his own utility and explored its theoretical and empirical implications. The maximization of his own utility which is a function of his income and leisure time should reflect the fact that the physician's conscientious behavior is relied upon for the effective delivery of medical care in Japan. Our empirical results found that revenues and net profits of clinics are critically related to the quantity of drugs used, the age of physicians and the size of clinics. This finding gives some support to the oft-heard allegation in Japan that physicians maximize their income by prescribing more drugs and examinations.

Ambulatory Care Facilities↗