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PubMed2000

Health plan competition in local markets.

OBJECTIVE: To examine the structure of local health insurance markets and the strategies health plans were using to respond to competitive pressures in local markets in 1996/1997. DATA SOURCES/STUDY SETTING: Community Tracking Study site visits conducted between May 1996 and April 1997 in 12 U.S. markets selected to be nationally representative. STUDY DESIGN: In each site, 36 to 60 interviews on local health system change were conducted with healthcare industry informants representing health plans, providers, and purchasers. DATA COLLECTION/EXTRACTION METHOD: Relevant data for this article were abstracted from standardized protocols administered to multiple respondents in each site. PRINCIPAL FINDINGS: Although the competitive threat from national plans was pervasive, local plans in most sites continued to retain strong, often dominant, positions in historically concentrated markets. In all sites, in response to purchaser pressures for stable premiums and provider choice, and the threat of entry and to plans were using three strategies to increase market share and market power: (1) consolidation/geographic expansion, (2) price competition, and (3) product line/segment diversification that focused on broad networks and open-access products. In most markets, in response to the demand for provider choice, the trend was away from ownership and exclusive arrangements with providers. CONCLUSIONS: Although local plans were moving to become full-service regional players, there was uncertainty about the abilities of all plans to sustain growth strategies at the expense of margins and organizational stability, and to effectively manage care with broad networks.

Community Health Services↗
PubMed2000

'Fast track' carotid duplex scanning in a district general hospital.

UNLABELLED: 'Fast track' carotid scanning is designed to rapidly identify patients with significant symptomatic carotid stenosis and, thereby, allow prompt surgery. We review the outcome of patients referred to our open-access scanning service over 3 years and 6 months. A total of 807 cases (62% males and 38% females with a mean age of 64 years) were referred. The main presenting symptoms were TIA in 69%, amaurosis fugax in 11% and minor CVA in 8.3%. The mean time between referral and scan was 17 days. In 80% of the cases, the scan showed no significant disease and the patients were not seen in the clinic. Significant abnormality (stenosis > 70% or occlusion) was found in 20% of the patients. Of the total, 12% were reviewed in the out-patient clinic following which no action was taken, 2% had angiography but no surgery, while 5% had angiography and surgery. 1% were lost to follow-up. The mean delay from scan to operation was 36 days. CONCLUSION: Fast track scanning has led to early detection of surgically relevant carotid lesions and avoidance of delay in surgical intervention. It is an efficient and cost-effective practice.

Adolescent↗
PubMed1999

Do people attending a same day testing clinic discuss their need for a HIV test with their GP?

In the United Kingdom, people with HIV infection present with advanced disease and general practitioners (GPs) are currently an underused resource for HIV testing. We describe the reasons for using an open-access clinic rather than primary care for testing for HIV. People attending the clinic were asked to complete a questionnaire asking about GP registration, access, and whether HIV testing was discussed in primary care. Despite access to GPs, HIV testing in primary care was rarely discussed. If HIV testing is to move to a general practice setting, GPs could address the issues, such as the recording of sensitive information in notes, future life insurance, and confidentiality, which this report identifies as the main barriers for using primary care.

Family Practice↗
PubMed2000

The impact of open access flexible sigmoidoscopy: a comparison of two services.

BACKGROUND: Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of barium enema and tumour-stage migration. METHODS: This was a non-randomised comparison (over two one-year periods, four years apart) of two unselected groups of patients, with different inclusion criteria, in adjacent similarly populated health districts. One offered a nurse practitioner endoscopy service while the other had a doctor-led colorectal clinic. RESULTS: The doctor-led service with its broad inclusion criteria detected more colorectal cancers [13.2% versus 0.7%; OR = 16.05; 2.16-119.2]. Neither nurse practitioner (130 cases) nor doctor-led (262 cases) flexible sigmoidoscopy reduced the total number of barium enemas [Odds Ratio (OR) = 1.16 (95% CI 1.03-1.3)]. However, the doctor-led service did reduce the number of barium enemas requested by general practitioners (from 249 to 152). The total number of colorectal cancers (detected by all available methods) were similar [OR = 0.82 (0.53-1.25)] and both services resulted in a similar tumour-stage migration [OR = 1.39 (0.31-6.23)]. CONCLUSION: Open access flexible sigmoidoscopy services have minimal impact on the utilisation of radiology services. Broader inclusion criteria of doctor-led services produce a higher cancer-yield. Tumour-stage migration may be related to greater awareness of colorectal cancer symptoms rather than to the type of OAFS.

Barium Sulfate↗
PubMed2000

Wall Street comes to Washington: market watchers evaluate the health care system.

Purchasers are tolerating double-digit premium increases for health plans and agreeing to employee demands for open-access products and wide choice of doctors largely because of the robust economy and tight labor markets, according to a panel of analysts at the fifth annual Wall Street roundtable convened by the Center for Studying Health System Change (HSC). The analysts, who specialize in health care companies, also discussed the challenges facing managed care and how health plans are evolving. This Issue Brief reports on these and other trends, including employers considering defined contribution approaches, techniques to control pharmaceutical spending and the impact of the Internet on the health care system.

Delivery of Health Care↗
PubMed1975

Community electrocardiography.

The report of the Joint Working Party on General Medical Services (1973) considered in detail the provision of electrocardiographic services for general practitioners. These are based either on primary health care teams using their own apparatus, or on hospitals offering open-access to their cardiac departments.In this survey I attempted to compare the proportions of general practitioners using their own electrocardiographs with those using hospital-based apparatus, and with those without direct access to any electrocardiograph facilities, and to evaluate the use made of such services, when available.

Electrocardiography↗
PubMed2002

Patients with new onset haematuria: assessing the discriminant value of clinical information in relation to urological malignancies.

BACKGROUND: There is little information available to assist general practitioners (GPs) in deciding which patients with haematuria are likely to have a malignancy. AIM: To derive discriminant functions for specific items or clusters of clinical history information in relation to the categorisation of patients presenting to the 'open access' haematuria clinic in Hull. DESIGN OF STUDY: Recruitment of patients via an 'open-access' haematuria clinic. SETTING: A consecutive series of 363 patients aged between 18 and 80 years who attended the clinic. METHOD: Between February 1999 and October 1999 clinical history information derived from the participating patients was compared with the patients' diagnoses. Diagnoses were established by a combination of cystoscopy and radiological assessments and rechecked against the patient records and the hospital patient administration system two to three months later. RESULTS: A number of individual variables seemed to be particularly helpful in discriminating malignancies. However, when indicants were combined using regression shrinkage techniques, only the following variables were preserved: age, sex, type of haematuria, number of episodes of haematuria, hesitancy, poor urinary stream, smoking history, and history of urinary tract infections. CONCLUSION: It is possible to generate helpful discriminant information to assist GPs in making more appropriate decisions in a difficult area of clinical practice. However, it remains a matter of judgement as to how representative the study population is likely to be compared with all haematuria patients encountered in primary care. We have reasonable confidence in the general applicability of the rules for macroscopic haematuria: however, it seems likely that the prediction rules outlined for microscopic haematuria have their greatest relevance once a patient has been referred by a GP. In developing the work further and testing out the discriminators identified in this study, we propose that a primary care-based project now needs to be undertaken focusing on microscopic haematuria with a particular emphasis on addressing selection biases. In addition, there is a more general need to assess the reliability of all the suggested items of clinical discriminant information.

Adolescent↗
PubMed2003

The yield of UGIE: a study of a ten-year period in the 'Zaanstreek'.

BACKGROUND: Study of the occurrence of abnormalities in the oesophagus, stomach and duodenum, and of changes in specific diagnoses. METHODS: All consecutive upper gastrointestinal endoscopies (UGIEs) carried out in a period of ten years were included. RESULTS: In ten years 14,927 diagnostic UGIEs were performed (7335 men (49%) and 7592 women (51%)). These procedures were done at the request of the general practitioner in 4995 (33%) cases. A steady yearly increase in the number of open-access UGIEs was noted. Each year a mean of 796 abnormalities was seen in the oesophagus, a mean of 437 in the stomach, and of 162 in the duodenum. The presence of hiatal hernia and reflux oesophagitis significantly increased in the ten years (p < 0.001). The numbers of Barrett's oesophagus and oesophageal cancer remained constant. Gastritis showed a gradual increase (p < 0.001), while the number of gastric ulcers found per year decreased significantly in the ten-year period (p < 0.001). Gastric malignancy remained constant. Presence of duodenal ulcers and bulbitis significantly decreased (p = 0.01 and p = 0.06, respectively). CONCLUSIONS: The number of UGIEs carried out at the request of the general practitioner has significantly increased. Peptic ulcer disease shows a significant decrease, while reflux disease increases.

Endoscopy, Gastrointestinal↗
PubMed2003

Spectrum of congenital heart defects associated with Down Syndrome in high consanguineous Omani population.

OBJECTIVE: To identify the pattern of congenital heart defects (CHD) in children with Down Syndrome (DS) in an Omani population, and compare it with CHD in children without DS and with historical cohorts from populations with low prevalence of consanguinity. SETTING: Open-access Paediatric Echocardiography Clinic at Sultan Qaboos University Hospital, Muscat, Oman. DESIGN: Prospective study. METHODS: All children with DS referred to the Clinic from 1995-1998 formed the subjects (Group I). Children without DS or other known associations of CHD seen at the clinic during the same period served as controls (Group II). Two-dimensional echo-Doppler studies were performed on both groups and the results compared. RESULTS: CHD were detected in 54/90 (60%) children in Group I, compared to 698/2122 (32.9%) in Group II (P<0.001). The common CHD in Group I included secundum atrial septal defect (ASD; 18/54), atrioventricular septal defect (AVSD; 15/54) and ventricular septal defect (VSD; 14/54), and in Group II included ASD (175/698), VSD (175/698), patent ductus arteriosus (123/698), pulmonary stenosis (PS; 76/698) and AVSD (35/698). AVSD was more common (P <0.001) and PS less common (P = 0.03) in Group I. Aortic stenosis, coarctation of aorta, transposition of great arteries and complex heart diseases were not detected. Compared to several studies from populations with low prevalence of consanguineous marriages, our study showed a higher frequency of CHD in DS (P <0.05). CONCLUSION: A high frequency of CHD was documented in DS-children from a population with widely prevalent consanguinity. AVSD was most frequent in DS. An interesting observation was the relative rarity of some CHD in the DS population studied.

Child↗
PubMed2003

[Crisis of the scientific communication].

Scientific communication is undergoing radical changes. The increasingly high prices of scientific journals and other barriers limiting their accessibility are important reasons. On the internet, it is possible to archive and publicize articles with open access, thereby speeding up scientific communication and achievements. Thousands of researchers around the world and many institutions are in favour of open access, while commercial publishers fear losing their profits. The new open-access journals have a low impact factor, which is impending the transformation of the publication system.

Communication↗
PubMed2005

Economic valuation for sustainable development in the Swedish coastal zone.

The Swedish coastal zone is a scene of conflicting interests about various goods and services provided by nature. Open-access conditions and the public nature of many services increase the difficulty in resolving these conflicts. "Sustainability" is a vague but widely accepted guideline for finding reasonable trade-offs between different interests. The UN view of sustainable development suggests that coastal zone management should aim at a sustainable ecological, economic, and social-cultural development. Looking closer at economic sustainability, it is observed that economic analyses about whether changes in society imply a gain or a loss should take into account the economic value of the environment. Methods used for making such economic valuation in the context of the Swedish coastal zone are briefly reviewed. It is noted that the property rights context matters for the results of a valuation study. This general background is followed by a concise presentation of the design and results of four valuation studies on Swedish coastal zone issues. One study is on the economic value of an improved bathing water quality in the Stockholm archipelago. The other studies are a travel cost study about the economic value of improved recreational fisheries in the Stockholm archipelago, a replacement cost study on the value of restoring habitats for sea trout, and a choice experiment study on the economic value of improved water quality along the Swedish westcoast.

Animals↗
PubMed2005

Changes in the prosthodontic literature 1966 to 2042.

PURPOSE: To describe the growth and content of the prosthodontic literature over the last 4 decades, to make a prognosis on its probable development in the coming 4 decades and to discuss changes in the content of the International Journal of Prosthodontics (IJP) from its start in 1988 to 2004. METHODS: MEDLINE was searched for articles on prosthodontics published between 1966 and April 2004. All volumes of IJP were examined with respect to type, subject area and geographic origin of articles. RESULTS: Using the term "prosthodontics," the MEDLINE search produced 66,600 hits. The proportion of clinical studies increased from 1% during the first 10-year period to 13% since 2001. Articles on removable dentures decreased during the period reviewed, whereas those on implant prosthodontics increased. Randomized controlled trials were rare and often of inadequate quality. Literature reviews have become popular, but many do not follow current guidelines for systematic reviews. A marked change in geographic origin of articles in IJP has occurred, with a decrease in material from North America and an increase in that from Europe and Asia. The Internet and open-access publishing will probably have a great impact on the future development of the prosthodontic literature. CONCLUSIONS: Substantial changes have occurred in the prosthodontic literature between 1966 and 2004, and they can be expected to continue with the rapid development of information technology and increased use of the Internet.

Bibliometrics↗
PubMed2005

[Examination of patients with dyspepsia in areas with a low prevalence of Helicobacter pylori infection].

Examination of patients with dyspepsia is quantitatively a major task in gastroenterology. Several strategies have been used. In recent years the "test and treat strategy" has gained wide acceptance, because it is easy and without discomfort to the patient. The primary step in this strategy is a 13C-urea breath test for Helicobacter pylori. If the test is positive, the Helicobacter pylori must be eradicated. Only patients with alarm symptoms or refractory symptoms are offered gastroscopy. This strategy has been found useful in clinical trials performed in areas with a high prevalence of Helicobacter pylori infection. To examine whether these results are valid in clinical practice in a low-prevalence country, we performed a one-year retrospective study of our modified strategy of 666 patients, in which gastroscopy is offered to patients who test negative--an "open access test and scope strategy". In all, 576 patients were referred and examined according to the strategy; 90 patients, of whom 43 had alarm symptoms, were referred erronously. We performed 322 breath tests, of which 66 were positive--49 in patients without alarm symptoms. Of the latter, 39 were improved by Helicobacter pylori eradication therapy. These were the patients who really benefitted from the strategy. Of the 230 patients with a negative breath test, 197 agreed to have a gastroscopy done, and 31 cases of oesophagitis and 3 idiopathic ulcers were found. It is concluded that the strategy is advantageous but complicated in an open-access setting.

Adolescent↗
PubMed2005

How do clinicians manage vaginal complaints? An Internet survey.

INTRODUCTION: Although vaginal symptoms are among the most common presentations in primary care, little is known about how clinicians manage them. QUESTION: We undertook an Internet survey to determine how clinicians decided what was normal, how they evaluated vaginal complaints, and what happened when a diagnosis could not be reached. METHODS: A 27-question anonymous survey was conducted using the Medscape Internet publication platform and Medscape General Medicine , an online, peer-reviewed, open-access general medical journal. The study was targeted at physicians and nurse practitioners. RESULTS: There were 556 nurse practitioner and 608 physician respondents. Clinicians generally agreed that a midcycle increase in discharge and discharge seen at the introitus were normal; itching/irritation, odor, and a green discharge were not. There was less agreement concerning the value of a yellow discharge and "self-diagnosis" of abnormality. Eighty-two percent of MDs and 77% of NPs reported examining patients prior to treatment always or often. Only about 30% performed pH testing always or often. Ninety percent of NPs and 92% of MDs reported not making a diagnosis rarely or sometimes. When offered 4 different management strategies for patients in whom no diagnosis was made (watch and wait, symptomatic therapy, empiric antibiotics, referral), there was no clear preference. There was a weak correlation between performance of a wet mount and reports of less non-diagnosis. There was no correlation between pH and whiff testing and reports of less non-diagnosis. CONCLUSIONS: Clinicians do not always agree about what constitutes a vaginal symptom. Although most providers usually examine patients with vaginal complaints, pH and whiff testing are performed less frequently. Our data suggest the latter 2 maneuvers are not diagnostically helpful. There is no consensus regarding what to do when no diagnosis is made. Our findings suggest that the traditional approach to the evaluation of vaginal symptoms may have limited relevance for clinicians.

Female↗
PubMed2005

Sustained virological response rate to pegylated interferon plus ribavirin for chronic hepatitis C in African Americans: results in treatment-naïve patients in a university liver clinic.

OBJECTIVE: The sustained virological response (SVR) to non-pegylated interferon-based regimens for chronic hepatitis-C virus (HCV) has been lower among African Americans compared to Caucasians, a finding attributed to the high proportion of genotype-1 infections in African Americans. To determine whether such a difference in SVR is still present with pegylated interferon and ribavirin regimens, we analyzed SVR rates among treated racial groups according to genotype. METHODS: Consecutive treatment-naïve patients of multiethnic and racial backgrounds attending a university liver clinic received either Peg alfa-2a or -2b plus ribavirin 1-1.2 g based on body weight for 24-48 weeks, depending on genotype. HCV RNA titers were analyzed at 0, six or 12 months, and six months posttreatment. RESULTS: Among the first 193 patients eligible for treatment, 73 received therapy [24 African Americans (genotype 1 in 88%); 49 non-African Americans (genotype 1 in 59%)]. Of the 120 patients not treated (33% African-American and 67% non-African-American), most either had mild hepatitis on biopsy, normal ALT values, an untreated psychiatric condition or had a low expectation of treatment efficacy. SVR results for the 73 patients who completed treatment indicate that African Americans and non-African Americans with genotype 1 have similarly low rates of SVR (19% in African Americans compared with 24% in non-African Americans, p=NS). CONCLUSION: Sustained viral response rates in our open-access liver clinic are similar for genotype-1 African Americans compared to non-African Americans receiving pegylated interferon and ribavirin. The predominance of genotype 1 among African-American patients likely accounts for the lower response rates, but genotype 1 in other racial groups is associated with a proportionately lower SVR as well as a risk for delayed relapse after SVR.

Adult↗
PubMedDate not supplied

Computerized health information networks: house calls of the future?

The Cleveland Free-Net is the nation's first free open-access computer system providing health information to the public. An online survey was developed for the family medicine clinic housed within the Free-Net to study the characteristics of the users of the system and the reason they selected the Free-Net as a source of health information. Three areas were addressed: 1) user demographics; 2) content analysis of questions; and 3) reasons Free-Net was used instead of the person's own health care provider. An analysis of the initial system done in 1985 revealed that early users of the system were known to be predominantly white male professionals, generally in the 25-35 age range. In comparison to that profile, more of the users in this study were women, but the majority of users continued to be white male professionals. Questions asked can be classified in six categories: diagnosis, symptoms, treatment, medications, laboratory tests, and prevention. The main categories of medical concerns were cardiovascular, gastrointestinal, obstetrical, and gynecologic problems. Users tended to use the Free-Net for health information rather than their physician because the traditional means was not always appropriate for the life-style of this population.

Adult↗
PubMed1986

Upper gastrointestinal endoscopy--a view from general practice.

An open-access upper gastrointestinal endoscopy service for general practitioners is described. Between July 1981 and May 1985, 391 endoscopies were performed on 354 patients. In contrast to the results of other studies, demand for endoscopy and the pick-up rate for major lesions has remained steady, and the number of requests for barium meals has fallen by almost a quarter. Major lesions - cancer, gastric and duodenal ulcers and severe oesophagitis - were found in 33% of patients. Oesophagitis accounted for 28% of positive endoscopies and 18% of positive endoscopies in patients with barium negative dyspepsia. With scarce resources there may, however, be a case for ;selective' access to upper gastrointestinal endoscopy in the future.

Adult↗
PubMed1974

An appointment system in a teaching practice.

Some patients have difficulty in achieving an appointment to see a doctor in a university teaching practice. Only five per cent of patients indicated serious difficulty. Patients who discriminate in favour of seeing a particular doctor have greater difficulty. It is suggested also that some patients have the same difficulty if they are making an appointment to see a particular doctor.Clearly there is a need to explore the problem further to determine the nature of the difficulties which patients experience. It might then be expected that improvements can be made which will help patients to achieve appointments more easily. At the same time it has to be recognised that there may be some patients who will continue to have difficulty in achieving an appointment however much they are helped. Such patients may need access to community health care services in a manner entirely different from the appointment system.Most patients prefer to see their general practitioner by appointment. Both open-access surgeries and appointment systems cause difficulties for patients. The former is associated with the difficulty of long waiting periods and the second with difficulties in achieving an appointment. As some form of appointment system is likely to be continued, particularly for group practices and health centres, it is probably timely to audit patients' experience of achieving appointments.University teaching practices present general practitioners with unusual additional stresses on an appointment system. The full-time teacher's day is divided between service to patients and teaching or research. Any reduction in the availability of a particular doctor in a group may result in patients having difficulty in making an appointment. This argument could equally apply to any group of practitioners who have commitments other than to general medical services.

Appointments and Schedules↗