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PubMed2001

Effect of the Vaccines for Children program on physician referral of children to public vaccine clinics: a pre-post comparison.

OBJECTIVE: Started in late 1994, the Vaccines for Children (VFC) program is a major entitlement program that provides states with free vaccines for disadvantaged children. Some evaluation studies have been conducted, but they do not include individually matched pre-post comparisons of physician responses. This project studied the effect of the VFC on the physician likelihood of referring children to public vaccine clinics for immunizations. DESIGN: In 1999, trained personnel conducted a survey of a cohort of physicians who previously participated in surveys on barriers to childhood vaccination conducted before VFC implementation. Responses were matched, and pre- versus post-VFC comparisons were made. SETTING AND PARTICIPANTS: Minnesota and Pennsylvania primary care physicians selected by stratified random sampling and initially studied in 1990 to 1991 and 1993, respectively. MAIN OUTCOME MEASURES: Likelihood of referral of a child to a public vaccine clinic. RESULTS: On a scale of 0 to 10, physician likelihood of referring an uninsured child decreased by a mean of 1.9 (95% confidence interval: 1.2-2.5) from pre- to post-VFC. Two fifths (45%) of physicians reported that the VFC decreased the number of referrals from their practice to public vaccine clinics and 50% gave intermediate responses. Among physicians who participate in VFC, only 9% were likely to refer a Medicaid-insured child in contrast to 44% of those not participating. CONCLUSIONS: Physicians' reported referral and likelihood of referring Medicaid-insured and uninsured children has decreased because of VFC in Minnesota and Pennsylvania.vaccination/economics, vaccination/legislation and jurisprudence, immunization programs/economics, immunization programs/utilization, vaccines/economics, Medicaid/economics, national health programs United States, child health services.

Capitation Fee↗
PubMed2000

[Social change in the physician's role and medical practice caused by managed care in Switzerland].

Switzerland is the first European country where health maintenance organizations (HMOs) characterised by capitation (per capita lumpsum) and gatekeeping were implemented according to the HMO staff model known in the USA. The development of managed health care in Switzerland relies on the belief that adequate economic incentives and competition result in cost reduction and high quality health care. Whether this is true or not--in any case the deregulation of legally accepted forms of health insurance and managed care result in profound changes in the Swiss health care system. Observations are made by using expert interviews and analysis of documents. The implementation of managed care induces socio-cultural changes of the medical profession which are as profound as the induced economic changes. We discuss conflicts of interests among physicians using four main dimensions of conflict: (1) control, (2) monopolization, (3) valuation, and (4) specialization. In the HMOs we observe pronounced conflicts of the physicians' role. The changes of the physicians' role in HMOs is on the one hand the result of new duties. On the other hand it expresses strategies of coping with the role conflict between the main clinical duties and the new obligation to control cost and to monitor treatment via gatekeeping. In HMOs the teamwork of doctors and the quality control of care promotes the satisfaction of physicians with their work, however, it can also have dysfunctional effects.

Cost Control↗
PubMed1998

Evolution of the Viral Hepatitis Prevention Board--VHPB.

The Viral Hepatitis Prevention Board (VHPB) was formed in 1992 to provide authoritative information and advice on hepatitis B as an occupational hazard and to act as a scientific lobby group to promote hepatitis B vaccination as part of an overall risk reduction strategy. The VHPB published Viral Hepatitis, a newsletter whose format and content was designed to appeal to both professional and lay readers seeking information on hepatitis. The VHPB was successful in lobbying the European Parliament to add the Code of Practice on Vaccination to legislation protecting workers from occupationally acquired infections. The first initiative on occupational hepatitis B culminated in an international congress in March 1993 and the publication of 'Hepatitis B as an Occupational Hazard' in the WHO occupational health series. Since 1993 the Board has discussed HBV as a community acquired infection; control of hepatitis A (HAV) and eligibility for hepatitis A vaccine and combined hepatitis A and B vaccines; hepatitis C; and reviewed progress towards the control of HBV and the adoption of universal vaccination programmes in countries of low endemicity. A major international congress in Cannes in November 1993 took stock of actions taken to control hepatitis B as a community health risk in industrialised countries. The constitution and membership of the Board underwent significant change at the end of 1994. A Secretarial was located within the Centre for the Evaluation of Vaccination at the University of Antwerp to deal with all administrative matters and publications in peer reviewed journals. The format of Viral Hepatitis was re-focused to increase the scientific content. The Board extended its actions geographically in 1996 to include the countries of Central and Eastern Europe (CEE) and the Newly Independent States (NIS) of the former Soviet Union. The success of the VHPB has exceeded all the expectations of the founding members. The major focus of the annual programme of meetings and of publications remains on hepatitis B and its prevention through vaccination. But more and more the broad range of prevention and control strategies for all forms of hepatitis is dealt with.

Europe↗
PubMed1996

[Quality assurance in heart surgery. General and personal concepts].

In the era of managed health care quality assurance has become more and more important. In cardiac surgery immense costs have to be justified. Some of the patients might be treated alternatively with drugs or by cardiological interventions. Additionally, the operative risk is still not neglectable in cases with substantial comorbidities and advanced age. Therefore in Germany, a nationwide quality assurance system was established in 1992 covering more than 90% of the cases in more than 90% of the centers. The goals of quality assurance have to address the needs of the patients, insurance companies, and surgeons, and thereby define the primary endpoints for analysis: mortality, quality of life, and therapy costs including reinterventions. A precondition for a sufficient quality assurance system is the isolation of quality relevant data by multivariate analysis and its documentation. Weighing the different factors allows a risk stratification in order to compare the results of various centers with different patient populations. For every center an expected mortality is calculated, and compared with the observed mortality. By taking the average mortality into account a risk adjusted mortality is derived for every center, which is independent from the patient population. An automated continuous follow-up of the patients is essential and allows assessment of 30-day mortality, reinterventions and quality of life. In 1986, the German Society of Cardio-thoracic-surgery initiated the development of a multicentric method of quality assurance (Quadra). In 1992 the insurance companies agreed to cover the costs for the reduced documentation of 205 parameters for every patient undergoing CABG, valve surgery or repair of an aneurysm with the help of cardio-pulmonary bypass; a 30-day follow up is included. Isolation of risk factors has not been performed because the quality of the data was not considered valid due to incomplete documentation and non-rigorous data control. For the first time in 1990, New York State Department of Health published data on risk adjusted mortality in CABG separate for every hospital. Due to a lawsuit brought on by the journal "Newsday" the department was forced to publish the results of every surgeon. Each clinic reports 41 different patient parameters, which are controlled for completeness and accuracy by an independent committee. The efficacy of this system has been proved by a 41% reduction in mortality from 1989 to 1992 mainly due to changes in patient management. Raw mortality rates to different hospitals in CABG were published by the administration of the insurance companies in 1986 leading to misinterpretations by the public. In response, the Society of Thoracic Surgeons initiated a database to calculate risk adjusted data. Today, more than 50% of all US-American centers participate and more than 700,000 patients have been reported. The data is not controlled and the majority of participating hospitals are small community centers. We have developed a methodology of quality assurance which estimates the operative risks of an individual patient by calculating the survival curve of all patients with the same risk profile who have already been operated on in our center. An automated long-term follow-up at one and five years after surgery provides the data for the calculation. The development of an effective quality assurance in the US was forced by media and insurance companies. Presentation of incorrect or misleading data in Germany has already damaged the image of cardiac surgery and surgeons. Therefore, there are no alternatives to public presentation of risk-adjusted mortalities in order to regain trust. Fears of surgeons and hospitals with results below the average are serious and patients with a high mortality risk may be afraid of not being operated on, although the New York System shows that these fears have not become real...

Cardiac Surgical Procedures↗
PubMed1998

From Cannes 1993 to the present.

In 1993 the Viral Hepatitis Prevention Board focused its attention on the serious threat hepatitis B poses to the community at large. The Cannes 1993 meeting "Action Towards Control of Hepatitis B as a Community Health Risk" was the first initiative and the springboard for other activities. The rationale behind universal hepatitis B vaccination strategies and the prerequisites for implementing these strategies were analyzed. Background information on country-specific hepatitis B epidemiology and on the feasibility of vaccination strategies were presented and discussed. The congress participants concluded that it is insufficient and ineffective to focus a vaccination campaign on a limited subset of the population (the so-called 'risk groups'), and the need for universal hepatitis B immunization was clearly recognized. Since Cannes 1993 many countries have responded to the call for universal hepatitis B immunization. Many have performed economic evaluation studies, while others have initiated sero-epidemiological studies to generate input data for burden of disease calculation. These studies indicate that epidemiological and economic arguments cannot be used to delay the implementation of universal hepatitis B vaccination. Some countries have improved their surveillance systems and included viral hepatitis in the surveillance programmes. Others have put hepatitis B on the political agenda. Where are we now? In the six years since the Global Advisory Group of the Expanded Programme on Immunization set 1997 as the target for integrating HB vaccination into national immunization programmes world-wide, more than 90 countries have included hepatitis B vaccine as part of their routine infant or adolescent immunisation programmes. In the WHO European Region, Albania, Bulgaria, France, Germany, Italy, Luxembourg, Moldova, Poland, Portugal, Romania, Andora, Austria, Greece, Malta, Switzerland, Israel, Slovenia and Spain have implemented universal vaccination programmes. Belgium, the Netherlands and several other European countries are seriously studying the issues or are making budgetary provisions for the introduction of HB into their vaccination programmes. Most of the European countries which now use the vaccine routinely have started with adolescent immunization. Italy and France have begun with both adolescent and infant HB immunization. The rewards of effective implementation of immunization programmes in these countries are becoming apparent and their success offers an exemplary model for other countries. The deadline was 1997! In Europe, work remains to be done before interventions, that will bring us closer to the WHO goal of universal immunization and to the goal of controlling hepatitis B in the community, are implemented. To this end, the VHPB has continuously supported the efforts of countries in Europe to meet the WHO target by convening meetings of international experts and issuing publications on the prevention and control of viral hepatitis.

Europe↗
PubMed1979

Treatment costs for patients with head and neck cancer.

A national health program is inevitable if medical care costs continue to soar as they have in recent years. Those of us treating patients with cancer of the head and neck are aware that the costs are high, but many are not aware of the actual figures involved. In this study, five typical head and neck cancer patients were selected, and the costs incurred by these patients were calcualted. Both direct and indirect medical expenses were considered and are presented. In addition, we report the representative costs of various treatment modalities. An awareness of medical care costs plus appropriate consideration of them in the planning and administration of treatment may help to reduce health care expenses. If we do not control these costs, the government undoubtedly will.

Costs and Cost Analysis↗
PubMed1996

Cost-effective provision of cardiac services in a fixed-dollar environment.

In the Canadian single-payer system, all hospital payments, including payments for cardiac operations, are negotiated with the government annually. Each hospital is required to remain within 50 cases of its negotiated surgical target. Physicians are paid on a capitated basis and are subject to penalties if negotiated targets are exceeded. There is a computerized waiting list for cardiac operation, with patients classified by an urgency rating scale and objectives set for the maximum period for any given urgency category. Experience has shown that many patients are delayed in the queue, waiting longer than expected for surgical procedures. Waiting times are not influenced by age, sex, or reoperative status, but are influenced by factors such as the presence of multiple risk factors, the number of diseased vessels, stability or unstability of angina, left main coronary artery disease, and recent angioplasty. Waiting time has not been shown to affect operative mortality, the incidence of postoperative low-output syndrome, or length of hospital stay. Canada's 30-year experience with the provision of cardiac services under managed care may provide useful information to hospitals and physicians in the United States currently confronting capitation. The following overview focuses on two critical issues: negotiation of costs and management of patient waiting lists.

Canada↗
PubMed1994

The role of the sickness funds in the Belgian health care market.

This article reviews some of the salient features of the Belgian health care finance and delivery system. Special attention is paid to the role played by the third-party payers, i.e. the Health Insurance Associations (HIAs) in administering the compulsory national health insurance program. It is shown how, despite extensive government regulation, the markets for GP, specialist and hospital services exhibit fierce competition of the non-price variety. Next, the paper considers the three problems perceived to be the most pressing ones at present: (i) the problem of raising sufficient revenues to cover the public share of health expenditures; (ii) the (related) cost containment problem; and (iii) the problem of ensuring efficiency through appropriate incentive mechanisms. Finally, two recently proposed options for reform are discussed and complemented with a third proposal based on the ideas of regulated competition. It is concluded that strengthening the role of the third-party payers remains crucial in any attempt to reshape the system to make it efficient and affordable while keeping it equitable.

Belgium↗
PubMed2006

Teenage mothers -- a high-risk group for new unintended pregnancies.

INTRODUCTION: One of the targets of national health programs is to prevent unintended pregnancies, especially among teenagers. It is well established that these often lead to abortion. Preventive programs aimed at decreasing abortion rates should identify target groups at risk for unintended pregnancies. PURPOSE: This study was conducted to determine whether young mothers under 20 years of age constitute a group at risk for new unintended pregnancies. METHODS: A retrospective cohort study comprising teenagers giving birth to their first child from 1996 to 2000 was performed at Orebro University Hospital, Sweden. Data were collected from antenatal and medical records with particular regard to compliance with the postpartum visit and to whether a contraceptive method was prescribed. Information concerning repeat pregnancies during the 12 months after delivery was obtained. RESULTS: A total of 250 deliveries were recorded; 70% of the mothers attended the postpartum visit, and 71% received contraceptive prescriptions. At the 12-month follow-up, 56 (25%) had a new pregnancy, and of those, 20 (36%) had a legal abortion, making the abortion rate fivefold higher than expected in this age group. CONCLUSION: This study shows that teenagers giving birth constitute a high-risk group for future unintended pregnancies and legal abortion.

Abortion, Induced↗
PubMedDate not supplied

Prenatal diagnosis of chromosome disorders in Tunisian population.

Cytogenetic prenatal diagnosis (PND) is under national health program in most developed countries, while it concerns a small part of population at risk in developing countries. Finance is common reason of absence of PND development, but socio-cultural believes play an important role in Arab Muslim countries. In this paper we report results of 3110 fetal karyotypes carried out in a Tunisian population, by cultured amniocytes analysis. It is the largest report in a Muslim Arab country in our Knowledge. Abnormal karyotypes rate was 4.18% classified in two groups: bad prognosis (3.05%) and good prognosis (1.13%). Common amniocentesis indication was maternal age. The highest predictive value was observed in balanced karyotype and fetal ultrasound findings indications. Maternal serum markers were not commonly used for trisomy 21 screening. Pregnancy termination that is permitted by legal and religious authorities was accepted by 94,74% parents. Information about PND outcomes was given by genetic counselling prior to fetal sampling, pregnancy interruption was discussed with parents at cytogenetic result announcement. The authors conclude that in order to prevent mental and physical handicap related to cytogenetic disorders we have to promote PND by education for population, genetic counselling and fetal ultrasound screening; all three methods available in Tunisia.

Abortion, Induced↗
PubMed2003

Cancer in women.

Incidence, mortality and survival trends for the most frequent cancers affecting women are presented on a worldwide basis. Data sources are represented by several different cancer databases, as no single world cancer database covers these epidemiological measures. Monitoring cancer incidence, mortality and survival are fundamental indicators which allow estimates and predictions of geographical and temporal changes of these diseases, enabling the design and set-up of adequate cancer control activities and national health programs. The observed differences in cancer incidence, mortality and survival in more developed countries compared with less developed countries (as defined by WHO) are mainly due to different individual and social risk factors between the two geo-political areas. For some cancers, advancements in screening, diagnosis and treatment in the more developed areas were the most effective factors in reducing incidence and mortality as well as prolonging survival. These effects were not detected in the less developed areas because of the limited access to primary and specialist care.

Breast Neoplasms↗
PubMed2001

Association of carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) with serum lipid profile in the Finnish population.

BACKGROUND: Moderate consumption of alcohol may reduce mortality from vascular diseases. The beneficial effects of alcohol may partly be mediated by its effects on lipoprotein metabolism. We studied the connection between alcohol consumption and the serum lipid profile from a well-documented national health program study. METHODS AND RESULTS: Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) were used as biochemical markers for alcohol consumption. The laboratory analyses were carried out on 5675 subjects (3097 males and 2578 females). The subjects were divided into quartiles on the basis of CDT or GGT value. The highest CDT quartile and the lowest GGT quartile seemed to be associated with a favorable lipid profile and the lowest CDT quartile and the highest GGT quartile were associated with an unfavorable lipid profile. Serum high density lipoprotein (HDL) cholesterol values were significantly higher and triglycerides lower with increasing serum CDT concentrations for both men and women. Increasing serum GGT was associated with higher serum total cholesterol and higher triglycerides in both men and women and lower HDL cholesterol in men. CONCLUSIONS: CDT and GGT seem to detect different populations of subjects in regard to lipid metabolism. These observations may lead to a better understanding of the effects of alcohol consumption on lipids as well as mechanisms behind favorable and detrimental effects of alcohol on vascular diseases. CONDENSED ABSTRACT: Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl-transferase (GGT) were used as biochemical markers for alcohol consumption. A total of 3097 males and 2578 females were divided into quartiles on the basis of their CDT or GGT values. The highest CDT quartiles had higher HDL and lower triglycerides, whereas the highest GGT quartiles appeared to be associated with higher total cholesterol and triglycerides in both genders and lower HDL in men. CDT and GGT seem to detect different populations of subjects in regard to lipid metabolism. These observations may have important clinical and public health implications.

Adult↗
PubMed1998

Universal hepatitis B immunization: young adolescent immunization.

Hepatitis B (HB) vaccines are safe and effective. To control HB infection at a population level, use of this vaccine in a routine immunization programme targeted at specific age groups has been recommended. Young adolescents (10 to 13 yr of age) are a group which may well be considered for such a programme, especially if school-based. This paper outlines some of the rationale, advantages and disadvantages of targeting this age group for HB vaccine as well as providing some recommendations regarding operational matters related to such a programme.

Adolescent↗
PubMed1998

Report from Working Group 3 (the Czech Republic, Denmark, Finland, Norway, The Netherlands, Slovakia, Sweden and the UK).

The Czech Republic, Denmark, Finland, Norway, the Netherlands, Slovakia, Sweden and the UK all have very low HBsAg carrier rates; in the Scandinavian countries, for instance, carrier rates are on the order of 0.05%. Most countries in this group are unconvinced that the carrier rates and the burden of disease caused by new hepatitis infections warrant the expense of universal childhood immunization. In Scandinavia and the UK hepatitis B prevention programmes are based on immunization of high-risk groups. In Scandinavia (excepting Denmark), the UK and the Netherlands, pregnant women are screened and newborns of carrier mothers vaccinated. Only the Czech Republic and Slovakia--both of which now employ high-risk group strategies of hepatitis B prevention--have expressed interest in implementing programmes of universal hepatitis B vaccination of infants and/or adolescents.

Czech Republic↗