Non-medical Services Research Articles

The impact of the global economic crisis on HIV and AIDS programmes directed at women and children in Zambia

This investigation sought to ascertain the extent to which the global economic crisis of 2008–2009 affected the delivery of HIV/AIDS-related services directed at pregnant and lactating mothers, children living with HIV and children orphaned through HIV in Zambia. Using a combined macroeconomic analysis and a multiple case study approach, the authors found that from mid-2008 to mid-2009 the Zambian economy was indeed buffeted by the global economic crisis. During that period the case study subjects experienced challenges with respect to the funding, delivery and effectiveness of services that were clearly attributable, directly or indirectly, to the global economic crisis. The source of funding most often compromised was external private flows. The services most often compromised were non-medical services (such as the delivery of assistance to orphans and counselling to HIV-positive mothers) while the more strictly medical services (such as antiretroviral therapy) were protected from funding cuts and service interruptions. Impairments to service effectiveness were experienced relatively equally by (HIV-positive) pregnant women and lactating mothers and children orphaned through HIV. Children living with AIDS were least affected because of the primacy of ARV therapy in their care.

Demographic and Financial Determinants of Housing Choice in Retirement and the Rise of Senior Living

This study examines the demographic and financial determinants of housing choices of older Americans, and how they have changed over the past several decades. Using logistic regressions with the Panel Study of Income Dynamics (PSID), a nationally representative longitudinal survey from 1968 to 2011, we find that in earlier periods, greater wealth was associated with “aging in place” and a lower likelihood of living in senior housing. More recently, the relationship between wealth and senior housing has changed, and higher wealth has become associated with increased senior living. Underlying this change is a shift in the mix of senior facilities, from predominantly those focused on medical needs and skilled nursing to newer retirement communities with a higher level of non-medical services, activities and amenities. The move to senior housing has become, for many older Americans, a choice of lifestyle rather than a move based on medical or nursing needs.These trends suggest that the aging Baby Boom generation’s effects on senior living communities may extend beyond those merely related to its size. With a large number of high-wealth individuals in the Baby Boom generation, demand for high-end retirement communities may experience a particular rise in the years ahead. The age at which older Americans move into a senior facility has shifted forward over the past two generations, and the front edge of the Baby Boom generation will soon be approaching the age range when moving to a senior community becomes a realistic consideration.

Wearable Computer Network Design using Dual-Role WUSB Clustering

A recent major development in computer technology is the advent of the wearable computer system that is based on human-centric interface technology trends and ubiquitous computing environments. Wearable computer systems can be integrated with the wireless universal serial bus (WUSB) that refers to USB technology that is merged with WiMedia PHY/MAC technical specifications. A wireless body area network (WBAN) allows the integration of intelligent, miniaturized, low-power sensor nodes that monitor body functions and the surrounding environment. In this paper, we propose a method for multi-hop network extension of WUSB over WBAN protocol. Unlike a wired USB that physically separates the USB host and USB device, WUSB allows a device to separately function as both a WUSB host and WUSB device on a single transceiver; such devices are referred to as the dual role devices (DRD). By using this DRD function of WUSB protocol, we propose a WUSB clustering method to realize the multi-hop network extension of WUSB over WBAN protocol in wireless home networks. In the WUSB clustering method, a new DRD message format reserves 2-hop range private DRP (Distributed Reservation Protocol) resources. In the experiment results, efficiency of the WUSB clustering method is proven through throughput evaluation in viewpoints of medical and nonmedical multi-hop WBAN services.

The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care.

BackgroundSocial dimensions of health are known to contribute to what is often termed “patient complexity,” which is particularly common among patients with multimorbidity. Health-care professionals require tools to help them identify and manage these aspects of patient needs.ObjectivesTo examine: (i) the Patient Centered Assessment Method (PCAM), a tool for assessing patient complexity in ways that are sensitive to the biopsychosocial dimensions of health, in primary care settings in Scotland; (ii) the impact of the PCAM on referral patterns and its perceived value; and (iii) the PCAM’s perceived applicability for use in a complex patient population.DesignTwo studies are described: (i) a mixed-methods prospective cohort study of the implementation of the PCAM in primary care clinics; and (ii) a qualitative exploratory study that evaluated the value of the PCAM in a complex patient population.ResultsUse of the PCAM did not impact patient satisfaction or perception of practitioners’ empathy, but it did increase both the number of onward referrals per referred patient (9–12%) and the proportion of referrals to non-medical services addressing psychological, social, and lifestyle needs. Nurses valued the PCAM, particularly its ability to help them address psychological and social domains of patients’ lives, and found it to be highly relevant for use in populations with known high complexity.ConclusionsThe PCAM represents a feasible approach for assessing patient needs with consideration to the social dimensions of health, and allows practitioners to refer patients to a broader range of services to address patient complexity.

Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance Misuse.

Objectives. We compared substance use and SBIRT (Screening, Brief Intervention, and Referral to Treatment) services received for older adults screened by the Florida BRITE (BRief Intervention and Treatment of Elders) Project, across 4 categories of service providers. Methods. Staff from 29 agencies screened for substance use risk in 75 sites across 18 Florida counties. Clients at no or low risk received feedback about screening; moderate risk led to brief intervention, moderate or high risk led to brief treatment, and highest severity led to referral to treatment. Six-month follow-ups were conducted with a random sample of clients. Results. Over 5 years (September 15, 2006-September 14, 2011), 85 001 client screenings were recorded. Of these, 8165 clients were at moderate or high risk. Most received brief intervention for alcohol or medication misuse. Differences were observed across 4 categories of agencies. Health educators screening solely within medical sites recorded fewer positive screens than those from mental health, substance abuse, or aging services that screened in a variety of community-based and health care sites. Six-month follow-ups revealed a significant decrease in substance use. Conclusions. The Florida BRITE Project demonstrated that SBIRT can be extended to nonmedical services that serve older adults.

Using pay-for-success to increase investment in the nonmedical determinants of health.

The combination of fee-for-service payments and the US health care system's standing commitment to treating existing illness discourages spending on the behavioral, social, and environmental (that is, the nonmedical) conditions that contribute most to long-term health. Pay-for-success, alternatively known as social impact bonds, or SIBs, offers a possible solution. The pay-for-success model relies on an investor that is willing to fund a nonmedical intervention up front while bearing the risk that the intervention may fail to prevent disease in the future. Should the intervention succeed, however, the investor is repaid in full by a predetermined payer (such as a public health agency) and receives an additional return on its investment as a reward for taking on the risk. Pay-for-success pilots are being developed to reduce asthma-related emergencies among children, poor birth outcomes, and the progression of prediabetes to diabetes, among other applications. These efforts, supported by key policy reforms such as public agency data sharing and coordinated care, promise to increase the number of evidence-based nonmedical service providers and seed a new market that values health, not just health care.

Care of Military Service Members, Veterans, and Their Families

Over thepast 13 years,more than two million United Statesmilitary service members have been deployed to combat operations overseas, primarily in Iraq and Afghanistan. In addition to over 6,000deaths and several thousandcombat injuries, several hundred thousand service members (and their families) continue to struggle with deployment-related readjustment and medical and mental health challenges. These recent operations and their sequelae are a reminder of the longstanding issues faced by military service members, veterans, and their families in the United States and worldwide from previous wars, in addition to newly returning veterans who present newchallenges inhealingthewoundsassociatedwithmodern warfare. The recent conflicts have also inspired significant efforts to develop new knowledge regarding treatment approaches and new systems of prevention and care delivery that are better suited to effectively support service members and their families. However, more research, infrastructure changes, and resources are required to meet current and future needs. This book is a timely and an important milestone in the literature on the care ofmilitarymembers, veterans, and their families. Its strength lies in the collective expertise of its authors and editors who have produced unified and clear messages, including the message that the health and wellbeing of military service members and veterans is closely linked to that of their familymembers.Thebodyof information about military service, culture, families, and unique challenges (such as frequent separations, relocations and deployments, changes in family roles, stigma, access to care, and injuries and deaths), aswell as about themanystrengthsof servicemembers (such as a sense of pride and belonging, financial stability, role flexibility, family extendedness, and resilience) is a highlight of this book. TheDepartment ofDefense and related communitybased partners have made impressive progress in research, interventions, andresources in thecareofmilitary families(e.g., Child and Youth Services, Family Readiness Groups, Military OneSource, and FOCUS [Families OverComing Under Stress]) that should be widely disseminated. This aspect of this volume will help community providers better understand the needs of their service member and veteran patients and their families and is a considerable contribution to the field. Themost important conceptual contributions of this book are outlined in three fundamental factors: that combat exposure impactsmental and physical health; that deployment/ combat experiences of service members are closely linked to the health and well-being of their family members; and that themilitary is in constantfluxdue to changeand transitioning of members between military and civilian communities. Constant change between military and civilian communities is particularly important among National Guard and Reserve members (who constitute close to one-half of the ready force). Militarymembers/veteranswhomoveto theciviliansectormay live in areas where there is inadequate expertise specifically related to the needs of military members/veterans and their families. Thus, the health and care of military members, veterans,andfamilies isanationalandcommunityconcern,not just aconcern for theDepartmentofDefenseor theVeteransHealth Administration or a few agencies. This volume’s conceptualization and focus is an excellent initial blueprint for the community to support these service members and veterans. Other strengths include the organization of this volume into three broad sections: Fundamentals for Treating Military Service Members, Veterans, and Families; Military Service-Related Conditions and Interventions; and Meeting the Needs of Military and Veteran Children and Families. This greatly helps in enhancing conceptual clarity, knowledge, and awareness for community providers with limited exposure to military members/veterans to effectively direct attention and resources toward addressing the needs of military members/ veterans and their families. The chapters on Collaborative Care and Suicide in the second section are particularly impressive and informative. The ambitiousness of this book is commendable, although there were clearly challenges in deciding what to include in this volume.The authors have negotiated this challenge quite well, striking a good balance between in-depth coverage of important topics, including theoretical and recent research advances, while also offering a lot of practical information and resources for providers. Potentially future editions of this book could expand by including an international perspective of the issues facing veterans so that we might benefit from research and practice in other parts of the world. Additional attention to thewide range ofVeteransHealthAdministration services would be important as well (1). The timeof transitionbetween theDepartment ofDefense and civilian life as a veteran is one of opportunity in which returning service members can be screened, provided information about resources, and connected with services. Lack of basic needs, such as housing and employment support, can potentially exacerbate and contribute to readjustment challengesandshouldbeaddressedinconjunctionwithhealthcare needs. Every Veterans Health Administration medical center has a seamless transition team that provides outreach, case management, and coordination services to support returning veterans and their families. In summary, the experts who contributed to and edited this book have provided an important and much needed contribution to the field of military, veteran, and family care. This book will serve as an excellent resource for a wide range of medical and nonmedical service providers, increasing awareness of resources and new directions in meeting the unique needs of service members, veterans, and their families.

The restorative potential of senior centers

Purpose – The purpose of this paper is to help senior center managers and service researchers understand why some patrons experience health benefits, primarily fatigue relief, through senior center day services participation. Design/methodology/approach – The authors conduct two separate studies at a senior center. The first study represents a grounded theory that offers an original, basic social process regarding mental restoration in senior centers. The second study draws on Attention Restoration Theory (ART) and employs survey methodology. Findings – Senior center patrons who perceive a center's restorative stimuli experience health benefits such as relief from four types of fatigue, enhanced quality of life, and improved physical and mental well-being. Research limitations/implications – The paper shows that senior centers may be relatively inexpensive, non-medical services that can help patrons relieve fatigue symptoms, which are often treated with pharmaceutical medication and medical visits. A limitation is the small sample size, which restricts generalizability. Practical implications – The results show that senior center managers may promote patron health by fostering service designs and programs that allow members to temporarily escape from everyday life and interact in an ever-changing environment that fosters a sense of belonging. Social implications – Senior center day services help patrons relieve fatigue, and its symptoms, in an affordable, non-medical, and non-pharmaceutical manner. Originality/value – The paper clarifies the role of senior centers in patrons’ lives by drawing on ART. Senior centers that can offer patrons restorative environments are likely to play a significant role in patrons’ physical, social, and mental well-being.

Providing mental healthcare to immigrants

The article reviews recent evidence on improving access to mental healthcare for immigrants and best practice of care provision. Language barriers, different beliefs and explanatory models of illness, confidentiality concerns, stigma, reluctance to seek psychological help outside families, and social deprivation may prevent immigrants from accessing mental healthcare. Pathways are influenced by families, primary care practitioners, voluntary organizations, and social services. Interpreting services are often not available, and data documentation on immigrants' use of services is inconsistent. Nonmedical specific services for immigrants can be effective in outreach activities. Cultural training of staff can improve clinicians' attitudes and patients' satisfaction with care. Integrative approaches between primary and mental healthcare, psychoeducational programs, and technological innovations have been developed to improve access to care. Immigrants can face significant barriers in accessing mental healthcare. Strategies to overcome these barriers are as follows: increased coordination and communication between voluntary organizations, social services and mental health services; training of staff on cross-cultural issues; integration of mental healthcare with primary care; psychoeducational initiatives focused on families and broader social groups; and technology-based interventions.

FIMA--questionnaire for health-related resource use in an elderly population: development and pilot study

Due to demographic trends towards an ageing population resource use of health care will increase. By collecting health-related costs via questionnaires, the impact of socio-economic variables and other medical factors can be examined. In addition, only patient reported resource use accounts for out-of-pocket payments. Thus, it is necessary to develop an appropriate tool to collect the health-related resource use in an elderly population. The development of the FIMA (questionnaire for the use of medical and non-medical services in old age) was carried out in 6 steps. These included the determination of necessary questionnaire contents based on a literature review and the wording and layout were defined. Finally the questionnaire was tested in a pilot study and was modified. All direct medical and non-medical resource use excluding transportation and time costs were recorded. Productivity losses were not included. The recall time frames differed according to resource categories (7 days, 3 months, 12 months). For the pilot study, 63 questionnaires were analysed. The response rate was 69%. The questionnaire took an average of 21 min to complete. Three quarters of respondents completed the questionnaire without help and 90% rated the difficulty as easy or even very simple. There was good agreement between self-reported health-related quality of life and the resource use of nursing and domestic help (phi coefficient values between 0.52 and 0.58). The FIMA is a generic questionnaire which collects the health-related resource use within the older population groups.

Disparities in the Use and Quality of Alcohol Treatment Services and Some Proposed Solutions to Narrow the Gap

This study assessed racial-ethnic disparities in access to high-quality treatment for at-risk drinking and alcohol abuse in the United States and simulated strategies to narrow the gap. Longitudinal data collected in 2001-2002 and 2004-2005 from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed to examine racial-ethnic disparities in receipt of alcohol interventions that were provided in primary care and specialty treatment settings and that met published clinical guidelines. The sample consisted of 9,116 respondents who met criteria for at-risk drinking or alcohol abuse in 2001-2002. Simulation analyses projected how disparities in treatment services utilization might change if clinical guidelines promoted access to care in more varied health and human service settings. Compared with whites, members of racial-ethnic minority groups had less than two-thirds the odds of receiving an alcohol intervention over the roughly four-year study period (odds ratio [OR]=.62, p<.05). This disparity increased after adjustment for socioeconomic confounders and frequency of heavy drinking (adjusted OR=.47, p=.003). The most pronounced disparities were between whites and U.S.-born and foreign-born Hispanics. Simulation analyses suggested that these disparities could be partially mitigated by extending care into nonmedical service venues. Current efforts to extend evidence-based alcohol interventions into medical settings address an important need but are likely to increase racial-ethnic disparities in access to high-quality treatment. Partial solutions may be found in expanding the range and quality of alcohol-related services provided in alternative delivery sites, including faith-based and social service institutions.

Patients' valuation of the prescribing nurse in primary care: a discrete choice experiment

Recently, primary care in the United Kingdom has undergone substantial changes in skill mix. Non-medical prescribing was introduced to improve patient access to medicines, make better use of different health practitioners' skills and increase patient choice. There is little evidence about value-based patient preferences for 'prescribing nurse' in a general practice setting. To quantify value-based patient preferences for the profession of prescriber and other factors that influence choice of consultation for managing a minor illness. Discrete choice experiment patient survey. Five general practices in England with non-medical prescribing services, questionnaires completed by 451 patients. Stated choice of consultation. There was a strong general preference for consulting 'own doctor' for minor illness. However, a consultation with a nurse prescriber with positive patient-focused attributes can be more acceptable to patients than a consultation provided by a doctor. Attributes 'professional's attention to Patients' views' and extent of 'help offered' were pivotal. Past experience influenced preference. Respondents demonstrated valid preferences. Preferences for consulting a doctor remained strong, but many were happy to consult with a nurse if other aspects of the consultation were improved. Findings show who to consult is not the only valued factor in choice of consultation for minor illness. The 'prescribing nurse' role has potential to offer consultation styles that patients value. Within the study's limitations, these findings can inform delivery of primary care to enhance patient experience and substitute appropriate nurse prescribing consultations for medical prescribing consultations.

The development of HIV-related mental health and psychosocial services for children and adolescents in Zambia: The case for learning by doing

The success of antiretroviral therapy (ART) has sparked a global commitment to strengthen health systems for an improved response. The response, however, is largely biomedical. Far less attention and funding exist for mental health and psychosocial support services (PSS). While the evidence-base for these services is less developed, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has responded to glaring needs through a “learn by doing” approach. This paper documents lessons learned as we responded to expressed needs for child-centered HIV support in Zambia.We formed a multidisciplinary working group to improve support for children on ART. In collaboration with the Zambian Ministry of Health (MOH) and with support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), we began, in 2008, by implementing a pediatric HIV counseling course focusing on disclosure, adherence, and stigma. Play therapy and adolescent-support programs followed. In 2013, with funding from the Conrad N. Hilton Foundation, EGPAF established HIV and developmental delay centers.Through working with the Zambia MOH, we have forged a national response. This involved training pediatric HIV counselors, play therapy counselors, adult mentors and positive peer mentors, as well as clinicians and volunteers in HIV and early childhood development. We have learned that providing health workers with skills to dialog with HIV-affected children and families in honest and developmentally-sensitive ways yields results. Thousands of children have been reached and improved adherence and acceptance of one's status have been reported. Non-medical services have been developed by busy practitioners to meet glaring clinic gaps using a “learn by doing” approach. More resources are required to scale up these programs and for ‘good practice’ evidence to be gathered.

Rationale and design of the Miami Healthy Heart Initiative: a randomized controlled study of a community health worker intervention among Latino patients with poorly controlled diabetes.

BackgroundType 2 diabetes mellitus disproportionately affects the Latino community. Latinos with diabetes are also less likely to have adequate control of cardiovascular risk factors such as cholesterol and blood pressure. Community health workers (CHWs) are increasingly being used to address various health disparity conditions, including diabetes. However, evidence of their effectiveness from randomized controlled trials is limited.MethodsThe Miami Health Heart Initiative is a randomized controlled trial of 300 Latino patients with diabetes. Patients with hemoglobin A1c (HbA1c) ≥8.0% were recruited from Miami-Dade’s public hospital system. At baseline, all patients underwent phlebotomy, physical examination, and a structured 90-minute research interview. They were then randomized to either usual care or a CHW intervention called Cariño. For participants in the Cariño arm of the study, CHW services included assistance with nonmedical social services, health education, and patient navigation in which the CHWs serve as a bridge between patients and the health care system. These services were delivered through home visits, phone calls, and group visits. At 12 months, all subjects had a follow-up examination. The primary outcomes at 1 year are changes in systolic blood pressure, low-density lipoprotein, and HbA1c. Secondary outcomes include medication adherence, medication intensification, diabetes self-efficacy, physical activity, and self-reported fruit and vegetable intake.DiscussionThe Miami Healthy Heart Initiative is one of the first rigorously conducted randomized controlled trials to provide evidence on the impact of CHWs on diabetes intermediate outcomes among Latinos. If the data support our primary hypotheses, the study would lend added support to ongoing efforts to incorporate CHWs as part of our national efforts to reduce and ultimately eliminate health disparities.

Pre-travel preparation of US travelers going abroad to provide humanitarian service, Global TravEpiNet 2009-2011.

We analyzed characteristics of humanitarian service workers (HSWs) seen pre-travel at Global TravEpiNet (GTEN) practices during 2009–2011. Of 23,264 travelers, 3,663 (16%) travelers were classified as HSWs. Among HSWs, 1,269 (35%) travelers were medical workers, 1,298 (35%) travelers were non-medical service workers, and 990 (27%) travelers were missionaries. Median age was 29 years, and 63% of travelers were female. Almost one-half (49%) traveled to 1 of 10 countries; the most frequent destinations were Haiti (14%), Honduras (8%), and Kenya (6%). Over 90% of travelers were vaccinated for or considered immune to hepatitis A, typhoid, and yellow fever. However, for hepatitis B, 292 (29%) of 990 missionaries, 228 (18%) of 1,298 non-medical service workers, and 76 (6%) of 1,269 medical workers were not vaccinated or considered immune. Of HSWs traveling to Haiti during 2010, 5% of travelers did not receive malaria chemoprophylaxis. Coordinated efforts from HSWs, HSW agencies, and clinicians could reduce vaccine coverage gaps and improve use of malaria chemoprophylaxis.

Pre-exposure rabies vaccination among US international travelers: findings from the global TravEpiNet consortium.

People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010. We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation. Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations >6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination. Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations.

Faktor risiko kematian ibu sebagai akibat komplikasi kehamilan, persalinan dan nifas di Kabupaten Bima tahun 2011–2012

Abstrak: Angka kematian ibu (AKI) di Provinsi Nusa Tenggara Barat tahun 2010 yaitu sekitar 350/100.000 kelahiran hidup, masih cukup tinggi jika dibandingkan dengan angka nasional dan provinsi lainnya. Kabupaten Bima merupakan salah satu kabupaten di Propinsi Nusa Tenggara Barat yang memiliki kasus kematian ibu yang cukup tinggi pada periode tahun 2011-2012 yaitu 20 kasus. Depkes RI membagi 3 faktor yang mempengaruhi kematian ibu yaitu faktor medik, faktor non medik dan faktor pelayanan kesehatan. Penelitian dilakukan untuk mengetahui faktor–faktor risiko yang mempengaruhi kematian ibu, yang terdiri dari faktor medik, non medik dan pelayanan kesehatan. Jenis penelitian ini adalah studi kasus kontrol, dengan jumlah sampel sebanyak 20 kasus dan 60 kontrol. Pengumpulan data melalui wawancara menggunakan kuesioner, kemudian melakukan verifikasi dengan register yang ada di bidan, KMS ibu hamil dan dokumen otopsi verbal. Analisis data dilakukan secara univariat, bivariat dengan chi square test dan multivariat dengan metode regresi logistik. Hasil penelitian menunjukkan bahwa faktor-faktor yang dijumpai meningkatkan risiko kematian ibu adalah kadar Hb&lt;10 gr% (OR=15,19; 95%CI: 3,25-70,97), keterlambatan pengambilan keputusan (OR=9,28; 95%CI: 2,15-84,80) dan keterlambatan penanganan medis di fasilitas rujukan (OR=13,16; 95%CI: 2,28-104,86). Faktor yang paling berkontribusi terhadap kematian ibu adalah kadar Hb&lt;10 gr%. Upaya yang dapat dilakukan adalah peningkatan kadar Hb ibu hamil, peningkatan kemampuan bidan/dokter dalam memberikan penanganan dasar kegawat-daruratan obstetrik di puskesmas dan penanganan obstetrik esensial komprehensif di rumah sakit serta perbaikan sistem rujukan merupakan upaya pencegahan terhadap risiko kematian ibu.

Health care utilization and costs associated with adherence to clinical practice guidelines for early magnetic resonance imaging among workers with acute occupational low back pain.

To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP). Washington State Disability Risk Identification Study Cohort (D-RISC), consisting of administrative claims and patient interview data from workers' compensation claimants (2002-2004). In this prospective, population-based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags). We identified workers (age>18) with work-related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury. Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52-54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline-adherent imaging; utilization of chiropractic care was significantly lower (18 percent). Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out-patient, inpatient, and nonmedical services, and disability compensation.

Assessment of University Gynaecology Clinics Based on Quality Reports

Introduction: Quality reporting was initially implemented to offer a better means of assessing hospitals and to provide patients with information to help them when choosing their hospital. Quality reports are published every 2 years and include parameters describing the hospital's structure and general infrastructure together with specific data on individual specialised departments or clinics. Method: This study investigated the 2010 quality reports of German university hospitals published online, focussing on the following data: number of inpatients treated by the hospital, focus of care provided by the unit/department, range of medical services and care provided by the unit/department, non-medical services provided by the unit/department, number of cases treated in the unit/department, ICD diagnoses, OPS procedures, number of outpatient procedures, day surgeries as defined by Section 115b SGB V, presence of an accident insurance consultant and number of staff employed. Results: University gynaecology clinics (UGCs) treat 10 % (range: 6-17 %) of all inpatients of their respective university hospital. There were no important differences in infrastructure between clinics. All UGCs offered full medical care and were specialist clinics for gynaecology (surgery, breast centres, genital cancer, urogynaecology, endoscopy), obstetrics (prenatal diagnostics, high-risk obstetrics); many were also specialist clinics for endocrinology and reproductive medicine. On average, each clinic employs 32 physicians (range: 16-78). Half of them (30-77 %) are specialists. Around 171 (117-289) inpatients are treated on average per physician. The most common ICD coded treatments were deliveries and treatment of infants. Gynaecological diagnoses are underrepresented. Summary: UGCs treat 10 % of all inpatients treated in university hospitals, making them important ports of entry for their respective university hospital. Around half of the physicians are specialists. Quality reports offer little information on the differences in competencies or medical specialties. The statutory quality reports are not useful for patients and referring physicians when choosing a clinic.

Setting priorities in preventative services

We investigate opinions regarding which preventative services should be given priority funding; the importance of primary, secondary and tertiary prevention; and bivariate associations between the respondents’ sociodemographics, health status and lifestyle and their preferences. Computer-assisted personal interviews (CAPI) were conducted with participants from a regional quota sampling by sex, age and socioeconomic status (SES) in Germany. Participants were asked to indicate whether they would keep the status quo, expand or reduce health-care provision for eight primary, six secondary and four tertiary preventative services. Furthermore, they stated the importance of primary, secondary and tertiary prevention on a four-point Likert scale. Data were evaluated using contingency analysis and correspondence analyses. One hundred and three people completed the survey. The majority of participants opted for expanding non-medical primary preventative services like health education and counselling and for expanding secondary preventative services like cancer screening. For tertiary prevention, like rehabilitation, the desired service distribution depends on the specific preventative services. There were few differences in answers to the questions on the importance of the provision in primary, secondary and tertiary prevention. Bivariate associations between the respondents’ characteristics like age, SES, health status and lifestyle and their preferences could be observed. Primary preventative services and disease detection should receive more funds. No consistent pattern could be detected for tertiary prevention. Respondents expressed some differences of opinion on the importance of types of prevention. The differences are related to knowledge, personal circumstances and interests of the respondents.