Health Service Characteristics Research Articles

Child Healthcare in Two Farmworker Populations

Children in farmworker families are medically underserved. Little research has documented the healthcare of these children. This analysis uses data collected from two populations of Latino farmworker families, one located in western North Carolina and western Virginia, and the other located in eastern North Carolina, to describe and compare child healthcare utilization and mothers' satisfaction with their children's healthcare. Child, mother, household and health services characteristics are examined as causes of variation in child healthcare utilization and mothers' satisfaction for each farmworker population. Results highlight strengths in the provision of healthcare to farmworker children, including most receiving care at a consistent healthcare facility, age appropriate time since last visit, and satisfaction with the care received. Shortcomings in farmworker child healthcare include few having a consistent healthcare provider, and many not receiving visits with recommended frequency. Differences observed in child health services between the two populations include dissatisfaction with care received, perceptions that healthcare staff members are disrespectful, and difficulties with transportation. Further research is needed to determine the best means of providing care to this underserved population.

Recovery, psychosis and psychiatry: research is better than rhetoric

Recovery, psychosis and psychiatry: research is better than rhetoric

An Ecological Study on the Association of Public Dental Health Activities and Sociodemographic Characteristics with Caries Prevalence in Japanese 3-Year-Old Children

The aim of this ecological study was to determine the association of the frequency of dental health activities conducted as public health service and sociodemographic characteristics with caries prevalence in Japanese 3-year-old children using data for each municipality as one unit. Data on caries prevalence in 3-year-old children in 2000 were obtained from 3,251 municipalities (almost all municipalities in Japan). Caries prevalence for each municipality was recalculated using the empirical Bayes estimation model to make adjustments for variations in municipalities with small numbers of children. Explanatory factors included annual frequency of dental health activities such as dental health education and topical fluoride application programs and various sociodemographic characteristics. Multiple linear regression analysis was applied to examine the associations between caries prevalence and annual frequency of dental health activities with adjustment of other sociodemographic variables. Variations in caries prevalence in municipalities with small populations became smaller after being adjusted by the empirical Bayes estimation model. Multiple linear regression analysis showed significant associations of caries prevalence with sociodemographic characteristics such as the proportion of residents with university degrees, total fertility rate, and the proportion of workers in the manufacturing industry (p < 0.001). Annual frequency of topical fluoride application showed a significant but relatively weak association with caries prevalence (p < 0.001), explaining only 0.8% of the total variation in caries prevalence, whereas no correlation was found between caries prevalence and annual frequency of dental health education. It was concluded that the effect of the fluoride application service on caries prevalence in 3-year-old children, although statistically significant, was of far lower clinical significance than sociodemographic characteristics.

Emergency Department Visits for Suicidality in Three Hospitals

The purposes of this study were to describe suicidal persons who come to the emergency department (ED) and to examine the relationship between clinical and health service characteristics and decisions regarding post-ED care. Data were collected from three hospital EDs by means of a retrospective review of records. During the 1-month study period, 163 ED visits were for suicidal ideation (f = 110) or behavior (f = 53). The mean age of the patients was 36.5 years (range = 5-87 years); 51% were female patients. Clinical decisions about post-ED care tended to be cautious, regardless of a patient's level of suicidality, with 71% of patients either transferred for psychiatric evaluation or admitted to the psychiatric unit. Emergency department staff tended to be slightly more conservative than mental health professionals, but the difference in their decisions about disposition was not significant.

Missing Stage and Grade in Maryland Prostate Cancer Surveillance Data, 1992–1997

Missing data in cancer surveillance records are common; however, little information exists on the types of cases most likely to have missing data, or how missing data influence research or policy. Two clinical elements often missing in surveillance data are histologic grade and stage of disease. Missing data are either not clinically ascertained or not successfully abstracted. Prostate cancer cases (N=22,217) reported to the Maryland Cancer Registry during 1992-1997 were geocoded by residence and analyzed. Multi-level logistic regression was used to examine case attributes and area-level demographic, economic, and health services characteristics predictive of either missing stage or grade. A scanning statistic was used to explore geographic clustering of high and low rates of missing stage and grade within the state, before and after adjustment for significant variables from multi-level models. Older age, black race, missing grade, and higher county-level median income increased the likelihood of missing stage, whereas more recent year of diagnosis, higher blockgroup-level median income, and county-level rurality decreased the likelihood. Older age, missing or later stage, higher blockgroup-level median income, and more urologists per case in one's county of residence increased the likelihood of missing tumor grade, and more recent year of diagnosis, higher county-level median income, and rurality decreased the likelihood. Adjustment reduced statistically significant clusters of missing stage from six to two, and clusters of missing grade from three to zero. Results suggest systematic influences on missing stage and grade, which could be investigated with case-control follow-back studies.

Effectiveness of comprehensive disease management programmes in improving clinical outcomes in heart failure patients. A meta‐analysis

Disease management programmes (DMP) have been advocated to improve long term outcomes of heart failure (HF) patients. To summarise the evidence supporting DMP effectiveness in improving HF clinical outcomes. Eligible studies were located through a systematic literature search. Only randomised controlled trials (RCTs), enrolling HF patients, and allocating them to DMP or usual care (UC), were included. Information on study setting and design, participants' characteristics and interventions tested were collected. A study quality assessment was performed. Main clinical outcomes assessed were: all-cause mortality and (re)hospitalisations, HF-related (re)hospitalisations and mortality. Meta-analysis was performed according to both Yusuf-Peto method and random effects model. Thirty-three RCTs were included. Mortality was significantly reduced by DMP compared to UC: OR = 0.80 (CI 0.69-0.93, p = 0.003). All-cause and HF-related hospitalisation rates were also significantly reduced: OR = 0.76 (CI 0.69-0.94, p < 0.00001) and OR = 0.58 (CI 0.50-0.67, p < 0.00001), respectively. Different DMP approaches appeared to be equally effective (sensitivity analyses). DMP reduce mortality and hospitalisations in HF patients. Because various types of DMP appear to be similarly effective, the choice of a specific programme depends on local health services characteristics, patient population, and resources available.

Non-adherence among patients initiating antiretroviral therapy: a challenge for health professionals in Brazil

To assess the incidence, magnitude and factors associated with the first episode of non-adherence for 12 months after the first antiretroviral prescription. A prospective study of HIV-infected patients receiving their first antiretroviral prescription in public referral centers, Belo Horizonte, Brazil. Baseline assessment occurred at the moment of the first prescription and follow-up visits at the first, fourth and seventh month, from May 2001 to May 2003. Non-adherence was self-reported and defined as the intake of less than 95% of the prescribed doses for 3 days before the follow-up interviews. Cumulative and person-time incidence were estimated and Cox's proportional model was used to assess the relative hazard (RH) of non-adherence with 95% confidence interval for both univariate and multivariate analysis. Among 306 patients, the cumulative incidence of non-adherence was 36.9% (incidence rate 0.21/100 person-days). Multivariate analysis (P < 0.05) showed that unemployment (RH = 2.17), alcohol use (RH = 2.27), self-report of three or more adverse reactions (RH = 1.64), number of pills per day (RH = 2.04), switch in antiretroviral regimen (RH = 2.72), and a longer time between the HIV test result and the first antiretroviral prescription (RH = 2.27) were associated with an increased risk of non-adherence, whereas the use of more than one health service indicated a negative association (RH = 0.54). The current analysis has pointed out the importance of clinical and health service characteristics as potential indicators of non-adherence after initiating therapy. Early assessment and intervention strategies should be priorities in these AIDS public referral centres. Feasible and reliable indicators for the routine monitoring of adherence should be incorporated in clinical practice.

Factors Associated with Ease of Using Community-Based Systems of Care for CSHCN in Hawai’i

To study factors contributing to difficulty using community-based services by families of children with special health care needs (CSHCN) in Hawai'i. Data source was the 2001 National Survey of Children With Special Health Care Needs. The study population included the 449 respondents who were surveyed after additional items were added to the original questionnaire. Outcome of interest was "% of CSHCN whose families report community-based service systems are organized so they can use them easily." Explanatory variables included child health conditions (functional limitation, degree of severity, types of service needs), child and family characteristics (child age, maternal education, poverty level), and health services characteristics (partnership of family in decision making, family-centered coordinated care, adequate health insurance). Children with special health care needs comprised 11.0% of < 18 years old children. Overall, 69% of respondents reported that community-based services could be used easily. Logistic regression analysis showed that the odds of reporting difficulties in using community-based services were almost 5 times higher for families who did not partner in decision making, 2.9 times higher for families who did not receive family-centered coordinated care, and 2.7 times higher for families who did not have adequate health insurance compared with families who were satisfied with the care received. Need for services contributed independently to reporting difficulties in community-based service use. Contrary to the hypothesized associations, severe health conditions or limited functionality did not contribute significantly to reporting difficulties in service use. Families who reported difficulties in using community-based services were those who have children who need extensive and varied services. Lack of involvement in decision making, lack of coordinated care in a medical home, and insufficient health insurance were the main obstacles to their ability to use community-based services easily.

Rural residents' utilisation of health and visiting specialist health services

The purpose of the study was to identify the demographic and health service characteristics impacting on rural residents' utilisation of health and visiting specialist services in Western Australia. Focus group discussions were held with an age-stratified, randomly selected group of forty-eight residents in four rural Western Australian towns between May and June 2000. Discussions revealed a preference to use local health services for basic care and to travel for the treatment of major or severe illnesses. The focus group participants supported visiting specialist services, indicating a willingness to use them for consultations, diagnostic and minor procedures. Utilisation of visiting services was conditional on the provision of information on specialist reputation, service outcomes, integration of the service into local facilities, and recommendation by the local general practitioner. Numerous factors influence the service-seeking behaviour of rural patients. These factors need to be recognised and considered in the design and promotion of resident and visiting specialist services if the migration for health care is to be rationalised.

Critical care in internal medicine department: EBM approach and new organizational model for Italian National Health Service

During the last decade the number of over-60 patients with multiple organ dysfunction admitted in the Departments of Internal Medicine in Italy has considerably increased. Many of these patients are critically ill and needs to be treated by trained medical staff with experience in internal medicine and an olistic approach. Several studies carried out in ICUs show that prognosis of elderly patients affected by multiple organ dysfunction is related to the number and severity of comorbidity regardless of age. Furthermore many survived patients dismissed from ICUs cannot reach the previous level of performance and global quality of life. One randomized controlled trial on chronically critically ill patients compared performances of traditional intensive care units with low technology 'Special Care Unit' managed by specialist in internal medicine, supported by sub-intensive nursing. These units obtained comparable clinical outcomes (mortality, complications) and better value (economic cost, stay of hospitalization). On the basis of these data and the characteristics of Italian National Health Service, we created in our Department of Internal Medicine a 'protected area' for critically ill patients affected by internistic diseases with complex comorbidities needing continuous monitoring of vital parameters and therapies. Medical staff working in this area have been trained in emergency medicine and are supported by nurses ACLS (Advanced Cardiac Life Support) certified. This unity is constituted by four beds with monitoring of EKG, non-invasive blood pressure, pulse, oximetry, body temperature, connected with a central computerized unit. Moreover, in this room are available ABG, ph-metry, and CPR equipment. Currently in Italy, this kind of patients are admitted in ICUs, often with unappropriated use of resources or in Department of Internal Medicine with inadequate quality of care. We are planning a case-control study to compare the outcomes of patients admitted in our new 'protected area' with those of matched patients previously admitted in our Department of Internal Medicine. The results of this investigation could supply data to support the creation of other 'protected areas' in Departments of Internal Medicine in our country. Furthermore this new approach could promote the renaissance of the role of Internal Medicine in Italian National Hospital System and help to release resources for the ICUs and other specialties.

Accessibility of adolescent health services.

Adolescents represent a large proportion of the population. As they mature and become sexually active, they face more serious health risks. Most face these risks with too little factual information, too little guidance about sexual responsibility and multiple barriers to accessing health care. A typical descriptive and explanatory design was used to determine what the characteristics of an accessible adolescent health service should be. Important results and conclusions that were reached indicate that the adolescent want a medical doctor and a registered nurse to be part of the health team treating them and they want to be served in the language of their choice. Family planning, treatment of sexually transmitted diseases and psychiatric services for the prevention of suicide are services that should be included in an adolescent accessible health service. The provision of health education concerning sexual transmitted diseases and AIDS is a necessity. The service should be available thought out the week (included Saturdays) and within easy reach. It is recommended that minor changes in existing services be made, that will contribute towards making a health delivery service an adolescent accessible service. An adolescent accessible health service can in turn make a real contribution to the community's efforts to improve the health of its adolescents and can prove to be a rewarding professional experience to the health worker.

Predictors of Mastectomy for Women with Breast Cancer in the Greater Western Region of Sydney.

This population-based study examined predictors of mastectomy for women with breast cancer in the greater western region of Sydney (GWRS) in New South Wales (NSW), Australia in 1992. Patients with a first diagnosis of breast cancer in 1992, the year prior to population-based mammographic screening in the region, were identified through the NSW state cancer registry. Data on stage, treatment, and demographic and health service characteristics were obtained from hospital records for patients treated within the region. The 282 patients who received surgical treatment for operable disease were considered in this analysis. Logistic regression was used to determine the odds ratio (OR) for mastectomy in relation to predictor variables with adjustment for confounding where appropriate. Age was included in all regressions even though it was not statistically significant. The tumor characteristics that were significant predictors (age adjusted) of mastectomy were stage [I (referent); IIA: OR = 1.5 (ns); IIB / IIIA-B: OR = 6.3, p < 0.05] and tumor size [T0-1 (referent); T2: OR = 1.8, p < 0.05; T3: OR = 12.9, p < 0.05]. There was a significant linear trend (p < 0.05) for lower ORs for mastectomy in women treated by surgeons with a higher breast cancer caseload (adjusted for age and stage). Women from municipalities with high socioeconomic status had lower mastectomy rates than others (OR = 0.5, p < 0.05), adjusted for age, stage, and surgeon activity level. Distance of residence from the main referral hospital and radiotherapy unit did not affect mastectomy rates. This study documents factors, in addition to stage at diagnosis, that play an important part in decisions about surgery for women with operable breast cancer. The experience of the surgeon, measured by the number of breast cancer patients, had an effect, as did the socioeconomic status of the woman. The latter may act through educational characteristics and participation of women in decisions concerning surgery.

Characteristics of private health care services in Salvador, Bahia, Brazil

To study the organization of private health services in the city of Salvador, Bahia, Brazil, a survey was carried out in 1994 involving 174 facilities registered at the Brazilian Institute of Statistics and Geography - IBGE. Health services characteristics studied were the following: number of physicians, hospital beds, production and cost of outpatient services, and legislative aspects. Health services were classified according to the amount of resources each type of granting agency contributed to support outpatient care. We found that the majority (51.1%) of private health care services in Salvador do not depend on public funds. The main sources of revenue for health services are private health insurance (41.9%) and other kinds of private health plans (54%). These changes in the organization of health services challenge health planners to review strategies for municipalization of health care and the relations between public and private health services in Brazil.

Factors affecting choice of sterilisation among low income women in Paraíba, Brazil.

Despite the absence of a family planning programme, the prevalence of sterilisation in Brazil has increased substantially, such that it is used by relatively young women in poor areas of the country. Sterilisation is influenced more by the characteristics of the health service than by socioeconomic characteristics of the population.

O desafio da eqüidade no setor saúde

Os países que procuraram construir um sistema público universalizante de saúde depararam-se com o debate sobre a eqüidade como princípio fundamental de justiça social. O presente artigo discute esta problemática em suas bases teóricas e apresenta, em grandes traços, as características essenciais do sistema britânico de saúde e o seu rebatimento nesta questão, visando a subsidiar considerações sobre a realidade brasileira.

Hospital admission rates and the prevalence of asthma symptoms in 20 local authority districts.

Representative samples of 20-44 year old men living in 20 local authority districts in England were surveyed in 1986 by postal questionnaire and asked about symptoms associated with asthma and treatment for asthma. Regional health authorities provided information on all hospital discharges of men of the same age living in the same districts. Specific information was also provided on discharges where the primary cause of admission was for asthma. Admission rates for asthma were related to the prevalence of night time breathlessness and independently to the all cause admission rate for men of the same age. Admission rates were not significantly related to prescription rates of either corticosteroids or beta 2 agonists for symptomatic men. This lack of association is hard to interpret without further information on variation in the severity of disease. These data show that admission rates for asthma are not dictated solely by health service characteristics, such as availability of beds or the "style" of the physician, but also reflect need. More research is required on how best to reduce the local prevalence and severity of asthma.