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PubMed1994

Micro-level planning using rapid assessment for primary health care services.

This paper describes the use of a rapid assessment technique in micro-level planning for primary health care services which has been developed in India. This methodology involves collecting household-level data through a quick sample survey to estimate client needs, coverage of services and unmet need, and using this data to formulate micro-level plans aimed at improving service coverage and quality for a primary health centre area. Analysis of the data helps to identify village level variations in unmet need and develop village profiles from which general interventions for overall improvement of service coverage and targeted interventions for selected villages are identified. A PHC area plan is developed based on such interventions. This system was tried out in 113 villages of three PHC centres of a district in Gujarat state of India. It demonstrated the feasibility and utility of this approach. However, it also revealed the barriers in the institutionalization of the system on a wider scale. The proposed micro-level planning methodology using rapid assessment would improve client-responsiveness of the health care system and provide a basis for increased decentralization. By focusing attention on under-served areas, it would promote equity in the use of health services. It would also help improve efficiency by making it possible to focus efforts on a small group of villages which account for most of the unmet need for services in an area. Thus the proposed methodology seems to be a feasible and an attractive alternative to the current top-down, target-based health planning in India.

Community Health Centers↗
PubMed1998

Small area study of mortality among people living near multiple sources of air pollution.

OBJECTIVE: In the area of Malagrotta, a suburb of Rome (Italy), a large waste disposal site, a waste incinerator plant, and an oil refinery plant became operational in the early 1960s and have represented three major sources of air pollution. To evaluate the potential health risk due to airborne contamination around these point sources, a small area analysis of mortality was conducted. Cancer of the liver, larynx, lung, kidney, lymphatic, and haematopoietic systems were evaluated. METHODS: Sex and age specific mortality (1987-93) and population denominators (1991) were available for the census tracts of the metropolitan area of Rome. Standardised mortality ratios (SMRs) were computed separately for males and females in bands of increasing distance from the plants, up to a radius of 10 km. Stone's test for the decline in risk with distance was performed with increments in radius of 1 km; SMRs were also computed after adjusting for a four level index of socioeconomic status. RESULTS: No overall excess or decline in risk with distance was found for liver, lung, and lymphohaematopoietic cancers in either sex. For laryngeal cancer, an increased but not significant risk was found at 0-3 km and at 3-8 km. A significant decline with distance in mortality from laryngeal cancer was found among men (p = 0.03); the trend remained after adjusting for the socioeconomic index (p = 0.06). CONCLUSIONS: The study showed no association between proximity to the industrial sites and mortality for most of the several conditions considered. However, mortality from laryngeal cancer declined with distance from the sources of pollution. This result is interesting, as previous findings of an increased risk of laryngeal cancer near incinerators have been controversial.

Air Pollution↗
PubMed1994

Comparing standardized rates of events.

This paper reviews issues associated with testing a null hypothesis of the equality of, and generating descriptive statistics for, standardized rates of events--recurrent or non-recurrent. The variance estimation for rates of surgical procedures, hospitalizations, and health care expenditures is discussed in the context of small area analysis. The proposed approach for estimating the variance of standardized rates is independent of assumptions about the underlying distribution of rates, is widely applicable, and seems preferable to approaches derived under special, but uncertain, parametric assumptions. A statistic is suggested based on person-level data, which allows comparing both rates of events and variation in rates between independent groups. The proposed statistic does not depend on the underlying unknown distribution of the events and does not require restrictive assumptions such as equal variances among the competing rates.

Analysis of Variance↗
PubMed1999

Geographic variation in preventable hospitalization of older women and men: implications for access to primary health care.

This study demonstrates how readily available data and small area analysis can be used to identify potential problems of access to primary care services for older women and men. Gender and socioeconomic differences in rates of preventable hospitalization are examined. Using hospital discharge data, five county and twenty-four intra-county areas in Upstate New York are studied. There is significant variation in preventable hospitalization within counties. Areas having significantly higher rates of these hospitalizations tend to have higher rates for both women and men. Problems of access are associated with lower income areas for women and men.

Aged↗
PubMed2007

Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the utility of serial measurements of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) to detect acute cardiac dysfunction during weaning failure in difficult to wean patients with chronic obstructive pulmonary disease. DESIGN: Prospective observational cohort study. SETTING: A 14-bed general intensive care unit in a university hospital. PATIENTS: Nineteen patients mechanically ventilated for chronic obstructive pulmonary disease exacerbation who were difficult to wean. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cardiac and hemodynamic variables, arterial and central venous blood gas, breathing pattern, respiratory mechanics, indexes of oxygen cost of breathing, and plasma levels of NT-proBNP were measured and analyzed immediately before (baseline) and at the end of a spontaneous breathing trial. Eight of 19 patients (42%) were identified with acute cardiac dysfunction at the end of the weaning trial. Baseline NT-proBNP levels were significantly higher (median 5000, interquartile range 4218 pg/mL) in these patients than in patients without evidence of acute cardiac dysfunction (median 1705, interquartile range 3491 pg/mL). Plasma levels of NT-proBNP increased significantly at the end of the spontaneous breathing trial only in patients with acute cardiac dysfunction (median 12,733, interquartile range 16,456 pg/mL, p < .05). The elevation in NT-proBNP at the end of the weaning trial had a good diagnostic performance in detecting acute cardiac dysfunction, as estimated by area under the receiver operating characteristic curve analysis (area under the curve 0.909, se 0.077, 95% confidence interval 0.69-0.98; p < .0001, cutoff = 184.7 pg/mL). CONCLUSIONS: Serial measurements of NT-proBNP plasma levels provided a noninvasive manner to detect acute cardiac dysfunction during an unsuccessful weaning trial in difficult to wean patients with chronic obstructive pulmonary disease. The utility of this test as a complement of the standard clinical monitoring of the weaning trial deserves further investigation.

Acute Disease↗
PubMed2003

Ecological and individual predictors of maternal smoking behaviour. Looking beyond individual socioeconomic predictors at the community setting.

The aim of this study is to examine the prevalence of smoking during pregnancy by the individual mother's sociodemographic characteristics and ecological factors at the community level (suburbs). This analysis combined 1996 Australia Census and data on 3424 women attending Well-Baby-Clinics (WBC) between January 1996 and February 1998 within a region in South Western Sydney (SWS), Australia. The prevalence of maternal smoking was 31%. Maternal factors such as marital status, country of birth, education, occupation, socioeconomic status (SES), and types of antenatal care (ANC) were independent risk factors for maternal smoking. Small area analysis revealed suburbs within SWS with high rates of maternal smoking (47-57%). Community level characteristics such as low income, low educational level, young mothers, and unemployment can explain 85.7% of the variation in maternal smoking in SWS. Smoking during pregnancy is recognised as a serious risk factor to the unborn child. The present study draws attention to local community level factors, other than individual SES, which may be important when developing strategies for maternal smoking prevention programs.

Adolescent↗
PubMed2005

Regional variation in rates of low birth weight.

OBJECTIVE: Low birth weight (LBW; < 2500 g) is the result of complex and poorly understood interactions between the biological determinants of the mother and the fetus, the parent's socioeconomic status, and medical care. After controlling for these established risk factors, the extent of regional variation in LBW rates remains unknown. This study measures regional variation in LBW rates and identifies regions of neonatal health services with significantly high or low adjusted rates. METHODS: Linking the United States 1998 singleton birth cohort (N = 3.8 million) with county and health care characteristics, we conducted a small area analysis of LBW across 246 regions of neonatal health services. We measured observed rates and then used a multivariable, hierarchical model to estimate adjusted LBW rates by regions. We then stratified these rates by race for the 208 regions with adequate sample size. RESULTS: Observed LBW rates varied across regions from 3.8 to 10.6 per 100 live births (interquartile range: 5.0-6.8 [25th-75th percentile]; median: 5.9). After controlling for known maternal and area risk factors, 67 (27.0%) regions had rates significantly below and 98 (39.8%) regions had rates significantly higher than the national rate of 6.0 per 100 live births. Although black mothers were more likely to give birth to an LBW newborn, regional adjusted rates still varied > 3-fold within both black and nonblack subgroups. CONCLUSIONS: After controlling for known maternal and area risk factors, LBW rates markedly varied across US regions of neonatal health services for both black and nonblack mothers. Additional analyses of these regions may provide opportunities for regional accountability in pregnancy outcomes, LBW research, and targeted improvement interventions, especially in high-risk populations.

Cohort Studies↗
PubMed1994

Variation in mortality rates in Tel Aviv region municipalities.

Age, sex and cause-specific mortality rates in 1982-86 for eight municipalities in the Tel Aviv region were compared to comparable rates of a reference population--the 1984 Jewish population of Israel. Residents of Or Yehuda, Tel Aviv, Holon and Bat Yam had an elevated risk of dying. Of particular interest is the elevated risk among adult residents of the Tel Aviv municipality. Males and females aged 30-44 had excess mortality from heart disease and external causes of death, and males aged 45-64 from ischemic heart disease and external causes. Tel Aviv females aged 30-44 also had excess mortality from cerebrovascular disease and females aged 45-64 from malignancy. High mortality rates in these age groups contribute considerably to years of life lost, and it is suggested that local health service or governmental action should be taken to investigate and reduce the disparities. Small area analysis, as shown here, may provide considerable information for monitoring community health.

Adolescent↗
PubMed1995

Small-area variation in multiple causes of death in Sweden--a comparison with underlying causes of death.

BACKGROUND: The effect of using multiple causes of death, i.e. all causes of death mentioned on the death certificates, compared to using the underlying cause of death only for analyses of regional variation among small areas in mortality for asthma, diabetes, hypertensive disease and cerebrovascular disease was studied. METHODS: Standardized mortality ratios (SMR) were analysed for the different health administrative areas in Sweden using data from the Swedish cause of death register for the period 1987-1991. The SMR were calculated for each of the selected underlying causes of death as well as for multiple causes of death. The correlations between SMR for underlying and multiple causes were analysed. RESULTS: The highest level of correlation of the SMR between multiple and underlying causes of death was found for cerebrovascular disease (0.96) and the lowest for hypertensive disease in the age group 0-64 years (0.51). For hypertensive disease, diabetes and asthma, when using multiple causes of death some further areas were found to have high SMR and the level of significance was higher. Significantly high SMR using underlying causes of death were, however, not shown to be false when multiple causes of death were used. In the case of cerebrovascular disease little additional information was gained. CONCLUSION: By including multiple causes of death in small-area analysis more statistical outliers can be detected and the risk of false warning signals due to random effect can be limited. Analyses of underlying causes of death and multiple causes of death should preferably be combined.

Adolescent↗
PubMedDate not supplied

Hiding your criteria will never work.

In this era of managed care, the message has been that the health care industry has provided inappropriate or inefficient care, causing the ruination of medicine and ultimately of the U.S. economy. Published research data on small area analysis have demonstrated marked differences in utilization rates for the same surgical procedure in various locations. Researchers and others have logically surmised that criteria used by providers in recommending these procedures have also varied from location to location. Correction, therefore, will require attention to the establishment of logical and defensible criteria.

Evaluation Studies as Topic↗
PubMed1975

The impact of applied behavior analysis on diverse areas of research.

The impact of applied behavior analysis on various disciplines and areas of research was assessed through two major analyses. First, the relationship of applied behavior analysis to the general area of "behavior modification" was evaluated by examining the citation characteristics of journal articles in JABA and three other behavior-modification journals. Second, the penetration of applied behavior analysis into diverse areas and disciplines, including behavior modification, psychiatry, clinical psychology, education, special education, retardation, speech and hearing, counselling, and law enforcement and correction was assessed. Twenty-five journals representing diverse research areas were evaluated from 1968 to 1974 to assess the extent to which operant techniques were applied for therapeutic, rehabilitative, and educative purposes and the degree to which methodological desiderata of applied behavior analysis were met. The analyses revealed diverse publication outlets for applied behavior analysis in various disciplines.

Behavior Therapy↗
PubMed2006

Geographical variations in hospital use in Estonia.

The purpose of this study was to analyse the utilisation of inpatient care in Estonia. Using small-area analysis the age and sex of municipality residents and travel time to the nearest hospital were linked to the frequency of use and length of stay of respective inpatients. Adjusted hospitalisation and readmission rates decreased with increasing travel time to the hospital. The travel time effect on the length of stay was inconsistent. Despite differences in hospital utilisation among municipalities, geographical access to inpatient care was substantially diminished only for 3% of the population living further than 30 min from hospital.

Adolescent↗
PubMed1998

Physician partnering in Maine: an update from the Maine Medical Assessment Foundation.

BACKGROUND: The Maine Medical Assessment Foundation (MMAF) has involved the participation of hundreds of physicians in study groups to analyze data on small-area variation and assess physician decision-making patterns. In 1991 the MMAF model was replicated across a tri-state area (Maine, New Hampshire, and Vermont) in an effort called the Outcomes Dissemination Project. THE OUTCOMES DISSEMINATION PROJECT: Five specialty study groups, each meeting three times a year, examined local and national utilization data and guidelines and research findings, participated in outcomes studies and patient education, and disseminated their findings through society presentations and other feedback efforts. Physician surveys indicated that all but one of the study groups were successful in making their existence and activities known to the broader medical community. PARTNERING WITH PURCHASERS AND MEDICAID: In the "Partnership Projects," the MMAF and relevant study groups, collaborating with a Maine business coalition, analyzed variations in utilization across employers, types of health plans (for example, health maintenance organization, preferred provider organization, fee-for-service), and small areas. Through this process, coalition members learned about small-area analysis and the implications of variations in utilization for cost and quality. The first year of the collaborative projects focused on several issues, including the development and dissemination of a practice guideline for the care of patients with chest pain; the dissemination of a practice guideline for the treatment of patients with acute low back pain; and a project designed to address cesarean section rates. SUMMARY: Innovative partnerships have been crafted to allow the tenets of the MMAF's working relationships with the medical community to remain intact, ensuring the ongoing interest and cooperation of hundreds of Maine physicians.

Community Networks↗
PubMed1994

Why does geographic variation in health care practices matter? (And seven questions to ask in evaluating studies on geographic variation).

One of the most active fields in health services research is the study of "geographic variation," or disparities in rates of certain types of health care practices among large areas (such as countries or regions of a country) or small areas (such as countries or hospital market areas); "small area analysis" in particular has received much attention in journals and the popular press. Increasingly, data upon which to base studies of geographic variation are becoming available. This article poses questions to ask in applying studies on geographic variation to health care settings. Because findings from these studies may ultimately affect patient care, the questions are important for physicians as well as health services researchers. The questions are: 1) What events are to be analyzed? 2) What geographic units are to be analyzed? 3) How good are the data? 4) Are differences in rates due to chance alone? 5) Are high rates too high? 6) How is geographic variation to be explained? 7) What is the role of "presentation style" in explaining geographic variation?

Geography↗
PubMed1993

The utility of PRO data on surgical volume: the example of carotid endarterectomy.

As part of a small-area analysis of carotid endarterectomy (CE) surgery, this review of Medicare claims data for a 26-month period addresses variations in surgical volume, mortality, readmissions, and charges. A surprisingly high percentage of surgeons performing CE did few procedures, and surgical volume appeared to be associated with higher mortality and charges. The implications of these data for both hospital credentialing committees and management and for purchasers and consumers of care, as well as the ways in which the Health Care Financing Organization's (HCFA) Health Care Quality Improvement Initiative (HCQII) will reorder their relationships with peer review organizations (PROs), are discussed. This study is useful in addressing the potential of efforts by PROs to increase the quality of care under the HCQII.

Data Collection↗
PubMed2001

[Surgical therapy of rectal carcinoma. Portrayal of the current health care status within the scope of a district quality assurance study].

UNLABELLED: In an era of economic pressure, patient's participation in decision-making and evidence-based medicine, the need for quality assurance of medical processes in daily routine becomes increasingly important. The aim of this quality assessment study is to demonstrate the real state of surgical care of patients with rectal carcinoma in the context of a field study on quality management in oncology. METHODS: Prolective cohort-study, small-area-analysis. Between 01.01.1997 and 31.12.1998, all patients with newly diagnosed rectal carcinoma and treatment in the county of Marburg-Biedenkopf (252.975 inhabitants, 3 hospitals) were included in the study. Documentation included all variables (n = 82) relevant for primary surgical therapy according to guidelines and standards. RESULTS: 146 consecutive patients fulfilled the inclusion criteria. 93% underwent resection of the tumor. In 6.6% of these cases rigid rectoscopy for determination of the tumor's distance from the anal verge was not performed. In 16.9% the colon was not examined completely. In 98.5% the state of distant metastases was documented preoperatively. 93% of the patients with tumors in the upper/middle third of the rectum and curative-intent surgery (n = 68) received a sphincter-saving operation. For all curative-intent procedures negative resection margins were confirmed histologically. Complication rates were 31.6% for anterior resection and 46.9% for abdominoperineal extirpation. CONCLUSIONS: Comparative analysis of quality indicators revealed a predominantly good quality of care. Improving efforts can now be concentrated on few areas of suboptimal quality in the setting of internal quality management. Critical results require detailed analysis of the single cases. Thus, conditions requiring deviation from guidelines become apparent.

Adult↗
PubMed2004

A multilevel analysis of socioeconomic (small area) differences in household food purchasing behaviour.

STUDY OBJECTIVE: To examine the association between area and individual level socioeconomic status (SES) and food purchasing behaviour. DESIGN: The sample comprised 1000 households and 50 small areas. Data were collected by face to face interview (66.4% response rate). SES was measured using a composite area index of disadvantage (mean 1026.8, SD = 95.2) and household income. Purchasing behaviour was scored as continuous indices ranging from 0 to 100 for three food types: fruits (mean 50.5, SD = 17.8), vegetables (61.8, 15.2), and grocery items (51.4, 17.6), with higher scores indicating purchasing patterns more consistent with dietary guideline recommendations. SETTING: Brisbane, Australia, 2000. PARTICIPANTS: Persons responsible for their household's food purchasing. MAIN RESULTS: Controlling for age, gender, and household income, a two standard deviation increase on the area SES measure was associated with a 2.01 unit increase on the fruit purchasing index (95% CI -0.49 to 4.50). The corresponding associations for vegetables and grocery foods were 0.60 (-1.36 to 2.56) and 0.94 (-1.35 to 3.23). Before controlling for household income, significant area level differences were found for each food, suggesting that clustering of household income within areas (a composition effect) accounted for the purchasing variability between them. CONCLUSIONS: Living in a socioeconomically advantaged area was associated with a tendency to purchase healthier food, however, the association was small in magnitude and the 95% CI for area SES included the null. Although urban areas in Brisbane are differentiated on the basis of their socioeconomic characteristics, it seems unlikely that where you live shapes your procurement of food over and above your personal characteristics.

Adult↗
PubMed1998

Analysis of health service areas: another piece of the psychiatric workforce puzzle.

Planning for development of a national or regional psychiatrist workforce that is the appropriate size must consider numerous issues. They include the dynamics of workforce distribution, effects of managed care, reduction in potential residency slots, participation of international medical graduates, apathy toward the field of psychiatry, service area variations, and increased interest in allied mental health professions, along with the burgeoning global burden of psychiatric illness. This paper examines the application of two benchmark standards for the number of psychiatrists needed per 100,000 population--the standard developed by the Graduate Medical Education National Advisory Committee and the Average Requirement Benchmark--to the supply of psychiatrists in Georgia in 1996 by county and by health service regions, which are geographical units based on health care utilization patterns of Medicare and Medicaid recipients. Areas with a surplus or deficit of psychiatrists are identified. The findings provide contextual evidence of a surplus of psychiatric physicians in the most populous areas of the state, given a substantial presence of health maintenance organizations. The state's less populated rural areas may potentially benefit from a redistribution of the psychiatrist workforce. The authors recommend continued refinement of models to estimate psychiatric workforce needs and suggest development of a comprehensive model that uses needs-based, demand-based, and benchmarking approaches.

Benchmarking↗