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Trends in the prescribing of antidepressants following acute myocardial infarction, 1993-2002.
OBJECTIVE: There has been a substantial increase in the prescribing of antidepressants on a population basis and in particular serotonin reuptake inhibitors (SSRIs). SSRIs have lower cardiac toxicity than tricyclic antidepressants (TCAs). We examined how the prescribing of antidepressants to patients post-myocardial infarction (MI) changed in the decade 1993 to 2002, including the proportion accounted for by TCAs. METHODS: A population-based study cross-sectional time series analysis was conducted in which quarterly antidepressant prescription data were obtained for 1993 to 2002 for elderly Ontarians who had experienced an MI, as well as for age- and sex-matched controls with no history of MI. The number of patients varied per quarter, for a total of 68,870 post-MI patients and an equal number of matched controls. Covariates included age, gender, income, and number of medications dispensed in the past year. RESULTS: Post-MI patients were more likely to receive an antidepressant relative to controls, with an overall odds ratio (OR) of 1.34; 95% confidence interval (CI), 1.29-1.38. However, with adjustment for the number of medications received, post-MI patients were 20% less likely to receive an antidepressant relative to controls, adjusted OR = 0.81; 95% CI, 0.78-0.84. The proportion of antidepressants prescribed to post-MI patients accounted for by TCAs decreased, but the proportion of post-MI patients receiving a TCA remained stable at approximately 6%. CONCLUSIONS: Increases in the prescription of antidepressants, and in particular SSRIs, to post-MI patients reflect general population trends rather than any special importance attached to treating post-MI depression. The apparent greater likelihood that post-MI patients will receive an antidepressant is reversed when total number of medications is controlled, a proxy for medical utilization and comorbidity.
Ambulatory mental health treatment under universal coverage: policy insights from Israel.
Untested assumptions concerning ambulatory treatment have shaped mental health policies for decades. Three opinions prevail: (1) all use is alike; (2) any use leads to high use; and (3) all high use is discretionary and therefore excessive. These assumptions were tested, using data from a nationwide survey of ambulatory utilizers in Israel, a country that has universal coverage. The findings, based on detailed clinical and treatment records, challenge all three assumptions. Moreover, they document a diversity of clinical needs while also verifying substantial variations in the type, frequency, and duration of treatment provided to meet those needs. In brief, Israeli data do not confirm continuing concerns by policy makers about uncontrollable use of services with expanded mental health coverage. Special policy limitations on mental health treatment should be reconsidered in light of empirical evidence from a system without the restrictions that exist in the United States.
Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the Province of Manitoba.
OBJECTIVES: To assess the ability of an Adjusted Clinical Group (ACG)-based morbidity measure to assess the overall health service needs of populations. Data Sources/Study Setting. Three population-based secondary data sources: registration and health service utilization data from fiscal year 1995-1996; mortality data from vital statistics reports from 1996-1999; and Canadian census data. The study included all continuously enrolled residents in the universal health care plan in Manitoba. STUDY DESIGN: Using 60 small geographic areas as the units of analysis, we compared a population-based "ACG morbidity index," derived from individual ACG assignments in fiscal year 1995-1996, with the standardized mortality ratio (ages < 75 years) for 1996-1999. Key variables included a population-based socioeconomic status measure and age- and sex-standardized physician utilization ratios. DATA EXTRACTION METHODS: The ACGs were assigned based on the complement of diagnoses assigned to persons on physician claims and hospital separation abstracts. The ACG index was created by weighting the ACGs using average health care expenditures. PRINCIPAL FINDINGS: The ACG morbidity index had a strong positive linear relationship with the subsequent rate of premature death in the small areas of Manitoba. The ACG index was able to explain the majority of the relationships between mortality and both socioeconomic status and physician utilization. CONCLUSIONS: In Manitoba, ACGs are closely related to premature mortality, commonly accepted as the best single indicator for health service need in populations. Issues in applying ACGs in settings where needs adjustment is a primary objective are discussed.
"Another day in paradise": an unhealthy (?) US health care.
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Libertarian bioethics and religion: the case of H. Tristram Engelhardt, Jr.
This paper is a critique of certain moral perspectives that are found in the second edition of Engelhardt's Foundation of Bioethics. These views are spelled out in explicit detail in his second edition, and follow on the heels of a profound religious conversion. Engelhardt is an eminent bioethicist with strong religious convictions that overlay much of his writing. The author wishes to question some of the conclusions that Engelhardt reaches as they touch upon moral frameworks, pluralism, and a 'secular' bioethics.
Americans' views of health care costs, access, and quality.
For more than two decades, polls have shown that Americans are dissatisfied with their current health care system. However, the public's views on how to change the current system are more conflicted than often suggested by individual poll results. At the same time, Americans are both dissatisfied with the current health care system and relatively satisfied with their own health care arrangements. As a result of the conflict between these views and the public's distrust of government, there often is a wide gap between the public's support for a set of principles concerning what needs to be done about the overall problems facing the nation's health care system and their support for specific policies designed to achieve those goals.
Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada.
BACKGROUND: The addition of supplementary prenatal support may improve the health and well-being of high-risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community-based population of pregnant women. METHODS: Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling). RESULTS: Overall, those in the nurse intervention group were more likely to attend an "Early Bird" prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy-related topics but had little impact on resource use for mental health and poverty-related needs. Among those with added support, resource use among low-risk women was generally greater than among high-risk women. CONCLUSIONS: Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community-based resources. This finding was true even for high-risk women, although this intervention did not reduce the difference in resource use between high- and low-risk women.
Reframing the quest: health for all.
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The uninsured: emergency medicine's challenge to our political leaders.
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Access to oral health care - an Australian perspective.
The objectives of this paper are to give a brief description of the Australian context for its dental care services and to discuss some of the nationally recognized issues in access to dental care with special reference to the situation in the most populous state, New South Wales. Australia is the size of continental USA but with only around 21 million people, 85% of whom reside within 50 km of the coastline. Thus, access to health care has a strong urban-rural dimension. The universal healthcare coverage excludes dental care, 80-90% of which is delivered through traditional fee-for-service private dental care. A public dental care system exists with varying eligibility criteria from state to state, mostly directed at children, low-income individuals, pensioners, and defined disadvantaged groups. Thus, access to dental care also has a strong socioeconomic dimension with disadvantaged people having serious access problems and extensive waiting times. Government and other reports have documented considerable polarization issues both in oral health and in access to dental care. Suggested change strategies have ranged from broad political changes in the dental care system to local oral health promotion initiatives, but overall, dental care remains a pawn in state-commonwealth political squabbles. In response to strong public reactions documented shortcomings of the public dental care system the government of New South Wales has recently initiated a political inquiry into dental care. Unless new resources are injected and policy adjustments made, serious changes are unlikely.
Social inequality in the use and comprehensiveness of dental services.
Fair access is a value enshrined through universal insurance for health care in Australia. However, dentistry is not included in this system. As a consequence, there is a strong likelihood of inequalities in access to dental services among adults. Data from the 1989-90 National Health Survey were analysed to determine sociodemographic factors related to use and comprehensiveness of dental services. Age, income, age of leaving school and occupation were independently associated with the use of dental services, and occupation was associated with an indicator of comprehensiveness of care: self-reported extraction at the last visit. In different adult age groups these sociodemographic factors had different effects, with the disparities in use of dental services greater in older age groups. Planning of dental services in the 1990s and beyond should include not only the removal of financial barriers to dental services among adults but also attention to the specific barriers experienced by the elderly.
Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health?
BACKGROUND: Despite enormous public sector expenditures, the effectiveness of universal coverage for health care in reducing socioeconomic disparities in health has received little attention. STUDY OBJECTIVE: s: To evaluate whether universal coverage for health care reduces socioeconomic disparities in health. DESIGN: Information on participants of the 1990 Nova Scotia Nutrition Survey was linked with eight years of administrative health services data and mortality. The authors first examined whether lower socioeconomic groups use more health services, as would be expected given their poorer health status. They then investigated to what extent differential use of health services modifies socioeconomic disparities in mortality. Finally, the authors evaluated health services use in the last years of life when health is poor regardless of a person's socioeconomic background. SETTING: The Canadian province of Nova Scotia, which provides universal health care coverage to all residents. PARTICIPANTS: 1816 non-institutionalised adults, aged 18-75 years, from a two stage cluster sample stratified by age, gender, and region. MAIN RESULTS: People with lower socioeconomic background used comparatively more family physician and hospital services, in such a way as to ameliorate the socioeconomic differences in mortality. In contrast, specialist services were comparatively underused by people in lower socioeconomic groups. In the last three years of life, use of specialist services was significantly higher in the highest income group. CONCLUSIONS: Universal coverage of family physician and hospital services ameliorate the socioeconomic differences in mortality. However, specialist services are underused in lower socioeconomic groups, bearing the potential to widen the socioeconomic gap in health.
Patterns of use of flexible sigmoidoscopy, colonoscopy and gastroscopy: a population-based study in a Canadian province.
BACKGROUND & AIMS: Flexible sigmoidoscopy, colonoscopy and gastroscopy are important in the diagnosis and treatment of gastrointestinal (GI) diseases. Pressure on endoscopy resources is expected due to increased screening for GI cancers. The present study examined patterns of use of GI endoscopy in a Canadian province, Alberta, with universal health care insurance. METHODS: Data on physician payments from January 1, 1994 to March 31, 2002 were used to calculate age-sex adjusted rates and patterns of use. RESULTS: The gastroscopy rate increased by 17%, from 9.7 (95% CI 9.6 to 9.9) to 10.3 (95% CI 10.1 to 10.5). The colonoscopy rate increased by 105%, from 4.8 (95% CI 4.6 to 5.0) to 9.8 (95% CI 9.6 to 10.1). Flexible sigmoidoscopy rates declined by 10%, from 4.68 (95% CI 4.56 to 4.80) to 4.21 (95% CI 4.11 to 4.32). The increase in colonoscopy rates occurred in all age groups, whereas gastroscopy rates increased only in the older age groups. Regional variation in procedure rates was evident, but rural health regions did not have consistently lower rates than the large urban regions. A polypectomy was performed on 23.7% of male patients and 15.4% of female patients at time of colonoscopy. Rates of polypectomy for individual endoscopists ranged from 0% to 60%. CONCLUSIONS: There has been a marked increase in gastroscopy and colonoscopy rates, likely due to a broadening of indications rather than just increased use for cancer screening. Modest regional variation in rates exists, but there is no direct evidence of limited rural access to endoscopy. Reasonable polypectomy rates were seen but important variations between endoscopists exist.
Use of complementary medicine in Switzerland.
OBJECTIVE: Within the framework of the Swiss governmental Program of Evaluation of Complementary Medicine (PEK) we assessed the prevalence, use, perceived effectiveness and appreciation of complementary medicine (CAM) in Switzerland, according to published surveys. MATERIALS AND METHODS: Search was performed through electronic databases, by hand-searching and by contacting experts at universities, hospitals, health insurances, patient organizations and pharmaceutical companies. RESULTS: Surveys were carried out among the general population (40%), physicians (20%), hospitalized patients (30%) and obstetric institutions (5%). The number of publications increased strongly between 1981 and 2004. The mean +/- SD prevalence (use) of CAM is 49 +/- 22% and varies depending on the survey's topic and the population group interviewed. The acceptance, appreciation or demand for CAM among individuals specifically interviewed on CAM is 91 +/- 6%. When asked about favored general improvements in healthcare, 6.5% of the individuals spontaneously mentioned CAM. CAM therapies are considered to be effective by the majority of CAM users and by about 40% of cancer patients using CAM. Approximately 50% of the population stated a preference for hospitals that also provide CAM. 85% of the population wishes the costs for CAM to be covered by the basic health insurance. CONCLUSION: Approximately half of the Swiss population has used CAM. CAM treatment is considered to be effective by the majority of CAM users. About 50% of the population would prefer hospitals that also provide CAM therapies and the majority of the population wishes the cost for CAM therapies to be covered by basic health insurance.
The social consequences of psychiatric disorders, III: probability of marital stability.
OBJECTIVE: The associations of prior DSM-III-R disorders with probability and timing of subsequent divorce were examined. METHOD: The data came from the part II subsample (N=5,877) of the National Comorbidity Survey. The respondents completed a structured diagnostic interview that retrospectively dated age at onset of each of 14 lifetime DSM-III-R disorders and recorded ages at first marriage and divorce. These data were used to estimate survival models describing the relationships between prior disorders and subsequent divorce. In addition, simulations were used to estimate the number of years spent out of marriage because of these causal relationships in the total U.S. population. RESULTS: Prior psychiatric disorders were associated with a substantially higher risk of divorce. The simulations suggested that the effects of these associations in the U.S. population in the survey's age range are approximately 23 million lost years of marriage among men and 48 million lost years of marriage among women. CONCLUSIONS: Psychiatric disorders have a number of adverse consequences for those who suffer from them and for their families and communities. The results reported here suggest that an increase in the number of people who divorce and a decrease in the number of years of marriage in the population may be among them. The debate over whether society can afford to provide universal treatment for psychiatric disorders needs to take these costs into consideration.
Patterns of use of ambulatory mental health services in a universal care setting.
OBJECTIVE: As health care expenditures grow, it is important to understand whether mental health services are being used appropriately. This study examined participants' reasons for seeking the services of a psychiatrist or psychologist to determine the extent to which factors other than an existing clinical disorder, such as culture, stress, or lack of social support, played a role. METHODS: A total of 1,257 randomly selected students who were enrolled at the University of Geneva in 1997 and who had unrestricted access to psychiatric services were asked how many times in the past 12 months they had consulted a psychiatrist or a psychologist. The respondents' mental health, perceived stress, self-esteem, sense of mastery, and social support were measured with validated instruments. RESULTS: A total of 131 respondents (10 percent) reported an encounter with a mental health provider in the past year. In adjusted analyses, female sex, Swiss citizenship, a higher level of stress, and a lower level of mental health were significantly associated with a greater number of visits to a mental health specialist, and self-esteem, sense of mastery, and social support were not. CONCLUSIONS: The respondents' use of mental health services was determined by a lower level of mental health, indicating appropriate use of services based on clinical need. However, service use was also determined by consumer-related variables such as perceived stress and sociocultural characteristics.
Gaps in service use and in needs.
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