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PubMed1995

Simultaneous strategies to reduce demand for and problematic use of hard drugs.

The primary responsibility of (local) governments is to enable people to make healthy choices in order to promote public health. Social circumstances are important determinants of choices that people make. Social risk factors for problematic use of drugs should be reduced to a minimum. Health education goals need to be matched to the different developmental stages of drug use behaviours of subgroups in the population. Employment perspectives for school leavers form an essential ingredient of policies which aim to reduce the demand for 'hard' drugs in order to divert (young) people from drug careers. Primary preventive strategies form the backbone of public policies focused on reduction of demand for hard drugs. Primary preventive strategies are population based and implemented by the public and private sector. Secondary preventive strategies are focused on specific high-risk groups and aim to prevent the development of drug dependence and/or to reduce harm for drug users. Tertiary preventive strategies are directed at individual hard drug users and emphasize harm reduction and rehabilitation of drug users and seek to reduce the side-effects of problematic hard drugs use for the general population. Innovative applied research is needed to improve field methods for timely detection of problematic hard drug use. More information about 'invisible' (hidden) populations of integrated drug users may offer new insights and ingredients for preventive policies on hard drugs.

Criminal Law↗
PubMed1997

An analysis of the cost of incomplete abortion to the public health sector in South Africa--1994.

OBJECTIVE: To analyse the medical costs incurred in treating women for incomplete abortion. This study was performed in conjunction with a nationwide survey of women who presented to public hospitals with incomplete abortion in 1994. DESIGN: Cost analysis with two modified Delphi panels used to develop models of resource use reflecting three severity categories of symptoms and three hospital treatment settings. SETTING: Public hospitals in South Africa. PARTICIPANTS: A panel of 15 senior level obstetrician/ gynaecologists and a second panel of 11 patient care managers representing district, regional and tertiary level hospitals in 7 provinces. MAIN RESULTS: A conservative estimate of the total cost of treating women is R18.7 million +/- R3.5 million for 1994. An estimated R9.74 million +/- R1.3 million of this was spent treating women with 'unsafe' incomplete abortions. CONCLUSIONS: The management of incomplete abortion requires significant public sector expenditure. The long-term indirect costs to women, their families and communities are discussed and treatment costs estimated so that unmet needs for medical care resulting from unsafe abortions can be addressed.

Abortion, Incomplete↗
PubMed2005

Antibiotic use and resistance in public-sector hospitals in KwaZulu-Natal.

OBJECTIVE: To investigate a possible association between level of care, antibiotic use and antimicrobial resistance in 16 public-sector hospitals providing different levels of care in KwaZulu-Natal. DESIGN: A multicentre surveillance study was undertaken in 16 hospitals at three progressive levels of health care (district, regional, tertiary) where each hospital submitted 100 consecutive, non-repetitive isolates judged in the laboratory to be of potential clinical significance. Isolates were identified and susceptibility testing was undertaken using the Kirby-Bauer disc diffusion method with minimum inhibitory concentrations (MICs) extrapolated on an automated reading system. Isolates were grouped according to their natural resistance profiles, and percentage susceptibility, mean percentage susceptibility and standard deviation to each antibiotic were stratified within and across hospital levels. Antibiotic use data were expressed as the number of daily divided doses (DDDs) per 1000 patient-days. SETTING: Two tertiary, 9 regional and 5 district public hospitals in KwaZulu-Natal. OUTCOME MEASURES: Percentage susceptibility. RESULTS: There was a general trend among the 1 270 isolates of highest susceptibility in district hospitals, followed by regional and then tertiary hospitals. This is consistent with the referral system where health conditions become increasingly severe/complex requiring greater antibiotic use and broader-spectrum agents at progressive hospital levels, with statistical significance (p < 0.05) evident where sample numbers were relatively large. Trend variations could be associated with the qualitative and quantitative differences in antibiotic use, albeit without statistical corroboration. Three per cent of the total number of isolates were sensitive to all antibiotics tested and 6% were resistant to a single agent only. The remaining 91% showed acquired resistance to more than one drug. The standard deviation ranged from 0% to 55%. CONCLUSIONS: This study showed that resistance profiles among bacteria varied greatly within and across hospital levels. While antibiotic use varied as much, a statistically significant correlation between use and resistance could not be established. It was therefore postulated that the effect of selection pressure was obscured by other resistance determinants apparent in public hospitals in resource-poor settings. On a clinical level, the study showed that resistance profiles among bacteria vary too much to allow a national antibiotic policy as proposed in the standard treatment guidelines. Rather, such guidelines should be directed to specific profiles found in different hospitals and at different levels of health care. Regular surveillance to adjust such guidelines is essential.

Anti-Bacterial Agents↗
PubMedDate not supplied

A strategic supportive model for health prevention in the elderly: profile of a Puerto Rican geriatric population in a public health sector.

OBJECTIVE: To introduce the ASSUME study with the presentation of a clinical, socio-demographic, preventive and psychological profile of a geriatric population of patients who receive their health care in the General Internal Medicine Ambulatory Sector of our institution. METHODS: The Assume study is a prospective, randomized trial which is directed at increasing the participation of patients in preventive health care strategies at a primary, secondary and tertiary level. In this paper we focus on the initial stage of the process which aims to define and synthesize predisposing risk factors in the geriatric patient which would be amenable to primary, secondary and tertiary preventive strategies. Through a process of patient interview profiles of a physical, social and psychological nature are have been constructed. With the availability of this profile a clearer definition of the potential benefit of preventive strategies could be established. In this paper we present the initial profile of patients of all patients randomized to the study as of Sept. 01, 1997. RESULTS: A total of 123 patients have been enrolled with 48(39%) males and 75(61%) females. The mean age of patients is 70 years with a median of 68 years. Cardiovascular disorders establish the leading disease events in our population of patients with Hypertension in 85%, Ischemic heart disease in 50%, Myocardial Infarction in 19% and 40% with a history of Congestive Heart failure. Diabetes and Heart Failure were seen in 40%. An average of 4.4 prescribed drugs per patient was documented. A minority of patients took more than 7 drugs and none took more than 9 medications. Most patients (67 or 55%) had not required hospitalizations in the preceding 12 months and none of the patients required more than 4 hospitalizations. The average LOS was 8.60 days. The Preventive Medicine profile reveals a large number of un-vaccinated adults. Regular cigarette smoking was seen in 12%. We have used the body mass index as a measure of adequacy of weight. We highlight the number of patients who have a BMI equivalent to an obese, severely obese or morbidly obese category (41%). The number of patients who follow a prescribed diet was found to be 54 patients for 44% of the study group. With regards to the interventions primarily designed for early cancer detecting, approximately half of the patients undergo the recommended annual screening interventions. The screening of visual accuracy was reported in 54%, dental screen (24%) and auditory screening (15%). Nearly a quarter of patients have severe depression. The CAPE testing reveal that in the information and orientation section most patients presented none or light dysfunction(87%). In the conductual phase marked or severe impairment was detected in 12% of patients. In the mental ability section 22% of patients presented marked or severe impairment. CONCLUSION: The geriatric population studied would benefit from modalities which would increment the modern modalities for primary and secondary prevention of disease. Follow-up studies will allow the evaluation of the effectiveness of the conceptual model proposed, which would increment the patient participation in these preventive modalities.

Aged↗
PubMed2005

Comparative quality of private and public health services in rural Vietnam.

BACKGROUND: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. METHODS: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. RESULTS: There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. CONCLUSIONS: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.

Adult↗
PubMed2004

A transitional care service for elderly chronic disease patients at risk of readmission.

BACKGROUND: Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. OBJECTIVE: To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. DESIGN: A quasi-experimental controlled trial. SETTING: A large tertiary metropolitan teaching hospital. PARTICIPANTS: 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. INTERVENTION: Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. MAIN OUTCOME MEASURES: Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. RESULTS: There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. CONCLUSION: The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

Aged↗
PubMed1998

Growing use of laparoscopic cholecystectomy in the national Veterans Affairs Surgical Risk Study: effects on volume, patient selection, and selected outcomes.

OBJECTIVE: To study the introduction of laparoscopic cholecystectomy to the 43 tertiary-care university-affiliated Veterans Administration medical centers (VAMCs) participating in the National Veterans Affairs Surgical Risk Study from October 1991 through December 1993. SUMMARY BACKGROUND DATA: Previous studies in the private sector have documented growth in the number of cholecystectomies and falling clinical thresholds for cholecystectomy with the introduction of laparoscopic cholecystectomy. METHODS: The following were analyzed for changes over time: measures of patient preoperative risk, complexity of surgery, severity of biliary disease, numbers of procedures, postoperative length of stay, and 30-day postoperative mortality and general complication rates. RESULTS: The number of cholecystectomies performed laparoscopically increased, but the total number of cholecystectomies performed remained stable over time. The proportion of patients with acute cholecystitis, emergent cholecystectomies, and technically complex cholecystectomies did not change or increased slightly over time. Adjusted odds for postoperative general complications were lower for laparoscopic than for open cholecystectomy, but 30-day postoperative mortality and general complication rates for all cholecystectomies remained constant over time. Postoperative length of stay for all cholecystectomies fell significantly. Implementation rates of laparoscopic cholecystectomy varied widely between hospitals. Laparoscopic cholecystectomy was adopted more slowly and used in a lower percentage of cholecystectomies than in non-VA settings. CONCLUSIONS: In contrast to non-VA studies showing increases in overall cholecystectomy volume since the introduction of laparoscopic cholecystectomy, these VAMCs implemented laparoscopic cholecystectomy without growth in cholecystectomies or a change in the clinical threshold for cholecystectomy. Laparoscopic cholecystectomy was associated with better outcomes, but its introduction in the setting of stable cholecystectomy volume and biliary disease case mix did not change postoperative mortality and complication rates. The stable cholecystectomy volume and biliary disease case mix, slower adoption, and lower use of laparoscopic cholecystectomy contrast with previous reports and may result from differences in patients and organization and financing of VA versus non-VA settings.

Aged↗
PubMed2006

She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan.

OBJECTIVE: To assess the availability, utilization and functional capacity of the public health delivery system in terms of human resources, equipment, supplies and health provider knowledge regarding management of obstetric complications. METHODS: A cross-sectional study was conducted in March 2003 for Multan's public health delivery system. A complete inventory of equipment, supplies, drugs, staff availability and knowledge of obstetric complications management were assessed. RESULTS: The number and distribution of public sector facilities serving a population of 3.2 million was well beyond the minimum requirement for basic obstetric care but fell short for comprehensive Emergency Obstetrical Care (EmOC). Utilization patterns were skewed to the tertiary facility for normal and complicated deliveries. Partograms were not available, magnesium sulphate was only available at the tertiary facility, while basic supplies like iron and folate tablets, broad spectrum antibiotics, oxytocics, gloves and sutures were not available at primary or secondary facilities. Knowledge scores regarding management of obstetric complications were less than average, especially among nurses at basic or comprehensive EmOC facilities. Intensity of labour pains (nurses 59%) at basic EmOC facility and cervical dilatation by doctors at basic and comprehensive facilities were the most frequent responses for monitoring in labour. CONCLUSION: Strengthening the four interlinked health system elements--human resources, access to, use and quality of services is essential though not sufficient.

Adult↗
PubMed2004

Prescription and dispensing practices in public sector health facilities in Pakistan: survey report.

OBJECTIVES: To gather information on existing prescription practices, dispensing practices and patient satisfaction in government health services of the NWFP, Baluchistan and Punjab province. METHODS: A cross sectional study design was used for this purpose. Ten health care facilities were selected from each province keeping appropriate representation from first level health facilities, district health facilities and tertiary care hospital. Analysis of selected indicators was carried out on the basis of provinces, health facilities, gender and different age groups. RESULTS: Documentation of 914 responses was completed from three provinces. Almost equal distribution of encounters was maintained representing different health facilities. Forty seven percent of encounters involved children under 15 years of age. Female patients comprised of 56% and the mean age of the entire sample was 26 years. The mean dispensing time was only 38 seconds, the mean consultation time was 1.79 minutes and the average number of drugs per prescription turned out to be 2.7 out of which only 1.6 drugs were being dispensed from the facility. More than half of the prescriptions contained antibiotics and 15% of patients were prescribed with injectables. Only half of the patients expressed satisfaction with their visit to health facility. CONCLUSIONS: Like many other developing countries, prescription and dispensing practices are not satisfactory in public sector health facilities of Pakistan. Appropriate and workable solutions need to be developed and implemented in the country to improve systems. Regular audits and qualitative studies should become part of the effort.

Adolescent↗
PubMed2005

Structural and functional separation of the N- and C-terminal domains of the yeast V-ATPase subunit H.

The H subunit of the yeast V-ATPase is an extended structure with two relatively independent domains, an N-terminal domain consisting of amino acids 1-348 and a C-terminal domain consisting of amino acids 352-478. We have expressed these two domains independently and together in a yeast strain lacking the H subunit (vma13Delta mutant). The N-terminal domain partially complements the growth defects of the mutant and supports approximately 25% of the wild-type Mg(2+)-dependent ATPase activity in isolated vacuolar vesicles, but surprisingly, this activity is both largely concanamycin-insensitive and uncoupled from proton transport. The C-terminal domain does not complement the growth defects, and supports no ATP hydrolysis or proton transport, even though it is recruited to the vacuolar membrane. Expression of both domains in a vma13Delta strain gives better complementation than either fragment alone and results in higher concanamycin-sensitive ATPase activity and ATP-driven proton pumping than the N-terminal domain alone. Thus, the two domains make complementary contributions to structural and functional coupling of the peripheral V(1) and membrane V(o) sectors of the V-ATPase, but this coupling does not require that they be joined covalently. The N-terminal domain alone is sufficient for activation of ATP hydrolysis in V(1), but the C-terminal domain is essential for proper communication between the V(1) and V(o) sectors.

Adenosine Triphosphate↗
PubMedDate not supplied

[Health financing in Lebanon. I. Organization of health care services, coverage system and contribution of the Ministry of Public Health].

This paper intends to analyze the health care system in Lebanon from the organizational and financial points of view. It allows for an understanding of the health services' market by tackling it from different angles: supply versus demand, private versus public sectors, curative versus preventive services, hospital versus ambulatory care. This study necessitated a review of all previous surveys made in this field, during the after-war period. It also needed the daily collection and follow-up of pertinent data with all private and public agencies and concerned ministries, over a one-year period. In addition, a critical analysis has been made to the survey Conditions de vie des ménages, en 1997, that was carried out by the Central Administration of Statistics, that came to complete the missing data concerning household expenditures on insurance and health services. Especially that this survey covered the same period (1997), subject of this study. The paper reveals that, although the private sector is the main provider of both hospital and ambulatory care, private hospitals are flourishing on public money, whereas outpatients care is mainly financed by the households. Evidence shows that the Lebanese health care system succeeded in resolving the problem of accessibility to primary, secondary and tertiary health care, responding thus to the value of equity. But, at the price of an ever escalating cost, threatening the sustainability of the system. This is what is attained in this paper, as it shows clearly that expenditures on health have reached an alarming level of the GDP share. Our purpose being providing solid arguments in favor of reforming the health system.

Budgets↗
PubMed2005

Physical and psychological violence in Jamaica's health sector.

OBJECTIVE: To determine the prevalence of experiences with physical violence and psychological violence that health staff have had in the workplace in Jamaica, and to identify factors associated with those experiences of violence. DESIGN AND METHODS: A total of 832 health staff answered the standardized questionnaire that was used in this cross-sectional study. Sampling was done at public facilities, including specialist, tertiary, and secondary hospitals in the Kingston Metropolitan Area; general hospitals in the rural parishes; and primary care centers in urban and rural areas. Sampling was also done in private hospitals and private medical centers. RESULTS: Psychological violence was more prevalent than was physical violence. Verbal abuse had been experienced in the preceding year by 38.6% of the questionnaire respondents, bullying was reported by 12.4%, and physical violence was reported by 7.7%. In multivariate analyses there was a lower risk of physical violence for health staff who were 55 years or older, worked during the night, or worked mostly with mentally disabled patients, geriatric patients, or HIV/AIDS patients. Staff members working mostly with psychiatric patients faced a higher risk of physical assaults than did other health staff. Of the various health occupations, nurses were the ones most likely to be verbally abused. In terms of age ranges, bullying was more commonly experienced by health staff 40-54 years old. CONCLUSIONS: Violence in the health sector workplace in Jamaica is an occupational hazard that is of public health concern. Evaluation of the environment that creates risks for violence is necessary to guide the formulation of meaningful interventions for the country.

Adult↗
PubMed2002

The complex business of neuroscience.

It's a clinical line that usually takes a back seat to higher-profile services like cardiology, oncology and orthopedics. But hospitals are starting to pay more attention to neuroscience for a number of reasons, including its tertiary nature and the high volume of imaging studies involved. More importantly, it usually generates a profit.

Capital Expenditures↗
PubMedDate not supplied

The changing nature of work: workplace stress and strategies to deal with it.

Workplace stress is costing the developed and developing world roughly between 5-10% of Gross National Product per annum in sickness absence, premature retirement due to ill health and lost productive value in terms of services and products. In addition, it is costing the health services of countries an additional burden in terms of treatment and incapacity benefits. A three prong approach to stress management and prevention is provided, exploring primary interventions (risk assessment), secondary interventions (training and development) and tertiary interventions (stress counselling and support).

Absenteeism↗
PubMedDate not supplied

Adverse selection at academic health centers.

Market influences are placing many academic health centers (AHCs) in financial distress. Competitive forces threaten the core missions of AHCs, principally because of selective contracting, which has introduced price competition to medical care. This manuscript discusses the issue of adverse selection for AHCs, the probability that patients with higher levels of illness severity seek care at, or are referred to, AHCs. AHCs are particularly vulnerable to adverse selection because of their prominence as referral centers, their specialty composition, research expertise, and the socioeconomic status of patients located proximal to their centers. The adverse selection of AHCs increases the likelihood that health plans will trim their networks to exclude them. Health plans may still contract with AHCs for tertiary care only, but this will only worsen the adverse selection at AHCs.

Academic Medical Centers↗
PubMed1997

Using proprietary methods to evaluate acute care admissions to a Veterans Affairs tertiary care center: are the appropriateness criteria appropriate?

An important question for facilities monitoring acute care bed admissions with proprietary criteria is whether these methodologies remain valid after substantial changes to the criteria sets. This is especially true for publicly funded hospitals whose medical and social mission is often broader than that of private sector facilities for which insurance-based claim review is most relevant. To further address this issue, we used sequential sets (1994 and 1995) of InterQual Intensity, Severity, and Discharge criteria to assess a cohort of patients referred to our Veterans Affairs facility as acute care admissions between December 1, 1994, and February 28, 1995. We found that the appropriateness rate for the subset of medical admissions dropped from 88% when using the 1994 criteria set to 49% when using the more stringent 1995 criteria set (P < 0.001). We conclude that substantive changes to previously validated criteria sets require revalidation. Furthermore, consideration should be given to the role that insurance-based utilization review should play in publicly funded hospital systems.

Acute Disease↗
PubMed2006

Effect of social deprivation on mortality and the duration of hospital stay after a stroke.

BACKGROUND: We aim to assess whether social deprivation independently predicts case fatality after a stroke patient has been admitted to hospital, and to assess whether social deprivation affected duration of hospital stay. METHODS: Cohort study in a tertiary teaching hospital included consecutive patients admitted to hospital within 48 h of their stroke between 1988 and 1994. Outcome measures were case fatality at 1 year and length of hospital stay. The socioeconomic category was derived from the postcode sector of residence for the patients (Carstairs index). Cause of death was determined by data linkage to the Registrar General data for Scotland. RESULTS: 2,042 stroke patients were included. A significant age difference existed between the deprivation categories (76.0 +/- 10.9 years in the affluent cohort vs. 71.4 +/- 10.7 years in the deprived cohort). Smoking was more common in the deprived group. ECG findings and neurological score on admission were similar between the groups. No difference existed between groups for length of hospital stay (p = 0.793), and in the proportions remaining alive at 1 year (p = 0.416). When entered into a multivariate Cox regression analysis, the deprivation categories did not predict mortality. Age, sex, Philadelphia Geriatric Center Instrumental Activities of Daily Living (IADL) Scale Score, Orgogozo neurological score on admission, and ECG abnormalities were the significant predictors. CONCLUSIONS: Stroke patients living in more socially deprived areas had their strokes at an earlier age but were not at a greater risk of dying or longer hospital stay once they had been admitted to hospital.

Aged↗
PubMed1994

[Ideas contributing to the reform of the health sector in Chile].

General criteria are proposed for the organization of chilean health system. The fundamental ideas emphasize administrative decentralization, an effective and expedite intercommunication between different attention levels and a rationalization of the use of diagnostic procedures and treatments. The "basic health plan" features are outlined. The need for patient and family education and the access to tertiary medicine only through referrals is highlighted. The second part of article proposes changes in Medical Education. The need to reorient undergraduate medical formation towards solving outpatient problems and to extend specialization possibilities to all graduates, including Adult and Children general medicine training programs, is emphasized. The incorporation of basic economical concepts to the curriculum and group work training is considered beneficial. Finally, self-teaching behaviors and resolutive capacities in legal and ethical aspects should be encouraged in students. The potential teaching roles of future health reference, diagnostic and therapeutic centers is insinuated.

Adolescent↗