Private Patients Research Articles

NHS treatment of private patients still not commonplace

NHS treatment of private patients still not commonplace

Differences in health literacy profiles of patients admitted to a public and a private hospital in Melbourne, Australia

BackgroundHealth literacy refers to an individual’s ability to find, understand and use health information in order to promote and maintain health. An individual’s health literacy may also be influenced by the way health care organisations deliver care. The aim of this study was to investigate the influence of hospital service type (public versus private) on individual health literacy.MethodsTwo cross-sectional surveys were conducted using the Health Literacy Questionnaire (HLQ), a multi-dimensional self-report instrument covering nine health literacy domains. Recently discharged private patients (n = 3121) were sent the survey in English, public patients (n = 384) were sent the survey in English, Arabic, Chinese, Vietnamese, Italian or Greek. Eligibility included hospitalisation ≥24 h in last 30 days, aged ≥18 years, no cognitive impairment. Odds ratios were used to assess differences between hospital sociodemographic and health related variables. ANOVA and Cohen’s effect sizes compared HLQ scores between hospitals. Chi square and multiple logistic regression were used to determine whether differences between private and public hospital HLQ scores was independent of hospital population sociodemographic differences. ANOVA was used to review associations between HLQ scores and subgroups of demographic, health behaviour and health conditions and these were then compared across the two hospital populations.ResultsPublic hospital participants scored lower than private hospital participants on eight of the nine health literacy domains of the HLQ (scores for Active Appraisal did not differ between the two samples). Six domains, five of which in part measure the impact of how care is delivered on health literacy, remained lower among public hospital participants after controlling for age, education, language and income. Across both hospital populations, participants who were smokers, those who had low physical activity, those with depression and/or anxiety and those with 3 or more chronic conditions reported lower scores on some HLQ domains.ConclusionsOur finding of lower health literacy among patients who had received care at a public hospital in comparison to a private hospital, even after adjustment for sociodemographic and language differences, suggests that private hospitals may possess organisational attributes (environment, structure, values, practices and/or workforce competencies) that result in improved health literacy responsiveness.

Financial Incentives to Reduce Hospital-Acquired Infections Under Alternative Payment Arrangements.

OBJECTIVEThe financial incentives for hospitals to improve care may be weaker if higher insurer payments for adverse conditions offset a portion of hospital costs. The purpose of this study was to simulate incentives for reducing hospital-acquired infections under various payment configurations by Medicare, Medicaid, and private payers.DESIGNMatched case-control study.SETTINGA large, urban hospital system with 1 community hospital and 2 tertiary-care hospitals.PATIENTSAll patients discharged in 2013 and 2014.METHODSUsing electronic hospital records, we identified hospital-acquired bloodstream infections (BSIs) and urinary tract infections (UTIs) with a validated algorithm. We assessed excess hospital costs, length of stay, and payments due to infection, and we compared them to those of uninfected patients matched by propensity for infection.RESULTSIn most scenarios, hospitals recovered only a portion of excess HAI costs through increased payments. Patients with UTIs incurred incremental costs of $6,238 (P<.01), while payments increased $1,901 (P<.05) at public diagnosis-related group (DRG) rates. For BSIs, incremental costs were $15,367 (P<.01), while payments increased $7,895 (P<.01). If private payers reimbursed a 200% markup over Medicare DRG rates, hospitals recovered 55% of costs from BSI and UTI among private-pay patients and 54% for BSI and 33% for UTI, respectively, across all patients. Under per-diem payment for private patients with no markup, hospitals recovered 71% of excess costs of BSI and 88% for UTI. At 150% markup and per-diem payments, hospitals profited.CONCLUSIONSHospital incentives for investing in patient safety vary by payer and payment configuration. Higher payments provide resources to improve patient safety, but current payment structures may also reduce the willingness of hospitals to invest in patient safety.Infect Control Hosp Epidemiol 2018;39:509-515.

Abstract P1-17-10: Survival outcomes related to health care coverage in breast cancer patients with brain metastases in Brazil: A sub-analysis from the LACOG-0312 study

Abstract Background The incidence of brain metastases among women with metastatic breast cancer (MBC) ranges from 10 to 30% depending of breast cancer (BC) subtype. Inequities in the access to optimal treatment and shorter survival of BC by type of health care coverage were previously reported in an observational study in Brazil. The present analysis aims to analyze the impact of the type of health care coverage on survival outcomes of patients with MBC and brain involvement. Methods LACOG-0312 is a retrospective cohort study that enrolled patients with metastatic or locally advanced/recurrent unresectable BC diagnosed during 2012 in Brazil. Overall survival (OS) was defined as the time from the diagnosis of brain metastases and death from any cause. Comparisons were made using the Kaplan-Meier method based on the type of health care coverage (public vs. private) among patients who developed brain metastases. Cox regression analysis was performed for identification of independent prognostic factors associated with survival after brain metastases diagnosis. Results Among the 690 MBC patients included in the LACOG-0312 study, 145 (21%) were diagnosed with brain metastases. Of them, 94 (71,75%) were covered by the Brazilian public health care and 37 (28,25%) had private coverage. Baseline characteristics such as age at MBC diagnosis, stage IV at diagnosis and tumor subtypes were similar between both groups. Median time to develop brain metastases after diagnosis of MBC was 14 months in the whole population with no differences between public and private patients (13 vs. 17 months p=0.172). Median OS from the date of brain metastases diagnosis was similar for both groups: 10.0 months in private and 9.0 months in public health insured patients (HR 0.92 – 95%CI 0.55-1.51; p=0.729). In a multivariable analysis including type of health care coverage, only the triple negative BC subtype was associated with a worse survival post brain metastases diagnosis. Conclusion Our study indicates that health care coverage is not associated with survival outcomes in patients with MBC and brain metastases. Potential differences in the access to optimal care such as radiotherapy, surgery and systemic treatments may not play a significant role in the survival of theses patients possibly due to small clinical benefit of the current treatment options for brain metastases in breast cancer. Citation Format: Albuquerque C, Debiasi M, Werutsky G, Uema D, Cronenberger E, Cordeiro de Lima VC, de Sant'ana RO, Bines J, Santi PX, Goés RS, Liedke P, Batista MLM, Dybal V, Nerón YV, Beato CA, Borges G, Giacomazzi J, dos Santos LV, Ismael G, Rosa DD, Azambuja A, Andrade D, Martinez-Mesa J, Zaffaroni F, Barrios CH. Survival outcomes related to health care coverage in breast cancer patients with brain metastases in Brazil: A sub-analysis from the LACOG-0312 study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-17-10.

Abstract P4-10-17: Survival outcomes related to health care coverage in metastatic breast cancer in Brazil: A sub-analysis from the LACOG-0312 study

Abstract Background Metastatic breast cancer (MBC) is an incurable disease in which latest therapies have evolving and improving patients survival. Inequities in the access to optimal treatment and shorter survival of BC by type of health care coverage were previously reported in an observational study in Brazil. In Brazil patients with private health coverage have access to the most recent therapies, however the public health system does not provide several therapies approved for the treatment of MBC such as everolimus, trastuzuman, eribulin, TDM-1, pertuzumab among others. The present analysis aims to analyze the impact of the type of health care coverage on survival outcomes of patients with MBC. Methods LACOG-0312 is a retrospective cohort study that enrolled patients with metastatic or locally advanced/recurrent unresectable BC diagnosed during 2012 in Brazil. Overall survival was defined as the time from the diagnosis of MBC and death from any cause. Comparisons were made using the Kaplan-Meier method based on the type of health care coverage (public vs. private). Cox regression analysis was performed for identification of independent prognostic factors associated with overall survival. Results A total of 634 patients with MBC were included in the study. Baseline characteristics by type of health care coverage was similar for visceral disease (43% in public and 44% in private, p=0.78), age at MBC diagnosis (median 62 years in public and 64 years in private, p=0.25), BC subtype (p=0.89), however more patients public insured were metastatic at diagnosis (42% vs. 33%) and had performance status &amp;gt;= 2 (12% vs. 3%). The proportion of patients that received any first-line systemic therapy was similar in both groups (95.2% in public and 95.5% in private, p=1.0), however more patients with private insurance received second (82% vs. 71.6%, p=0.013) and third line (56% vs. 45%, p=0.024) therapy compared to public health covered patients. OS from the date of MBC diagnosis in whole population was 36 months. There was no difference in terms of OS between private (42 months) and public (35 months) health insured patients (p=0.65). OS by BC subtype was 15 months for triple negative, 23 months in HER2 positive, 44 and 42 months for Luminal A and B respectively. There was no difference in OS by type of health insurance coverage in any BC subtypes. In a multivariate analysis type of health care coverage did not associate with survival, only triple negative (HR (95% CI) – 3.495 (2.448 - 4.989); p &amp;lt;0.001), HER2 positive (HR (95% CI) - 2.287 (1.394 - 3.572); p = 0.001) BC subtypes and visceral metastases (HR (95% CI) – 1.413 (1.075 - 1.858); p &amp;lt;0.013) were correlated with a worse survival. Conclusion Our study suggestes that health care coverage is not associated with survival outcomes in patients with MBC. Potential differences in the access to optimal systemic treatments may not play a significant role in the survival of these patients. Real-world studies addressing the impact of new cancer therapies for different BC subtypes in MBC are needed. Citation Format: Werutsky G, Zaffaroni F, Uema D, Cronenberger E, Cordeiro de Lima VC, de Sant'ana RO, Bines J, Santi PX, Goés RS, Liedke P, Batista MLM, Dybal V, Nerón YV, Beato CA, Borges G, Giacomazzi J, dos Santos LV, Ismael G, Rosa DD, Azambuja A, Andrade D, Martinez-Mesa J, Debiasi M, Barrios CH. Survival outcomes related to health care coverage in metastatic breast cancer in Brazil: A sub-analysis from the LACOG-0312 study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-17.

Fatal collision? Are wireless headsets a risk in treating patients?

ABSTRACTWireless-enabled headsets that connect to the internet can provide remote transcribing of patient examination notes. Audio and video can be captured and transmitted by wireless signals sent from the computer screen in the frame of the glasses. But using wireless glass-type devices can expose the user to a specific absorption rates (SAR) of 1.11–1.46 W/kg of radiofrequency radiation. That RF intensity is as high as or higher than RF emissions of some cell phones. Prolonged use of cell phones used ipsilaterally at the head has been associated with statistically significant increased risk of glioma and acoustic neuroma. Using wireless glasses for extended periods to teach, to perform surgery, or conduct patient exams will expose the medical professional to similar RF exposures which may impair brain performance, cognition and judgment, concentration and attention and increase the risk for brain tumors. The quality of medical care may be compromised by extended use of wireless-embedded devices in health care settings. Both medical professionals and their patients should know the risks of such devices and have a choice about allowing their use during patient exams. Transmission of sensitive patient data over wireless networks may increase the risk of hacking and security breaches leading to losses of private patient medical and financial data that are strictly protected under HIPPA health information privacy laws.

Maternal-choice caesarean section versus planned vaginal birth in low-risk primigravid women.

Rising rates of caesarean section (CS) have been attributed, in part, to maternal-choice CS (MCCS). There are few published data regarding maternal and perinatal risks comparing MCCS with planned vaginal birth (VB) in uncomplicated first pregnancies to inform choice. We report the results of a pragmatic patient-preference cohort study of private patients in Australia: 64 women planning MCCS and 113 women planning VB. There were few differences in outcome between the two groups. The study highlighted the well-recognised difficulties in undertaking prospective research into MCCS.

Abstract TP314: Comparison of Patient-centered Outcome Measures of the International Consortium for Health Outcomes Measurements (ICHOM) Between Private and Public Healthcare System in Brazil

Introduction: An international experts panel was assembled to create a standard set of outcome measures for use in both low and high-income countries. Additionally, the panel intended to represent the most relevant outcomes for subsequent cost-effectiveness analysis. For implementing the tool, it was necessary to make it feasible in different healthcare systems. The objective of this study was to implement and compare the ICHOM outcome measures between two different stroke centers: a university public hospital and a private hospital. Methods: the medical data of all patients with stroke diagnosis consecutively admitted in the two hospitals were registered. ICHOM outcomes in the 3-month follow-up were measured by interviews in person, by phone or by e-mail, and the results were compared between the hospitals. Results: 90-day outcome measurements were available for 328 patients (169 in the private hospital and 159 in the public), corresponding to 87% of the patients admitted with stroke diagnosis in these hospitals. The mean age was 68 years in the private vs. 65 in the public, with a mean NIHSS of 7, and 90% had ischemic strokes (18% received IV thrombolysis in the private setting vs. 16% in the public). Public hospital inpatients had a greater number of comorbidities. The mortality rate was 14% in both hospitals, and functional independence (mRS 0-2) occurred in 51% of private setting patients and 39% of the public. The greater proportion of patients needing help for dressing or toileting, as well as having language issues, was in the public setting. Better outcomes were measured in the private hospital regarding the resumption of the social role (64% vs 40%), satisfaction with social activities (65% vs 57%) and good quality of life (66% vs 57%). In both hospitals, 34% had access to physiotherapy after hospital discharge. Conclusions: In patients with acute stroke from private and public hospitals the thrombolysis eligibility are similar, without increasing the mortality rates in the public setting. However, better functional outcomes were found in private patients, probably due to less comorbidities, better prevention and post-discharge rehabilitation care.

Abstract TP230: The Development of a Stroke System of Care in Brazil: Where Are We Now?

Introduction: The organization of the stroke care in Brazil started in 2002 after the tPA approval. In 2008, was started a task force of stroke neurologists together with the Ministry of Health (MOH) with the objective of supporting the establishment of a nationwide network. Since then, the hospitals have progressively improved their structure. In 2012, was launched the National Stroke Policy, by the MOH, with creation of stroke centers in public health system, reimbursement of tPA, implementation of telemedicine and creation of the Line of Care integrating all stroke assistance. The aim of this study is to compare the structure of stroke care in 2008 and 2017. Method: This cross-sectional study compared the structure of stroke centers in 2008 and 2017. The information was collected through online questionnaires sent to the stroke centers and to the vascular neurologists. Results: In 2008, 35 stroke centers were active (40% assisting public health patients), only 14% with stroke units and no hospital had telemedicine. The National Emergency Medical Service (EMS) was trained in 4 cities, covering 23% of stroke centers. In 2017, there are 139 stroke centers registered in Brazil. We had answers from 110 hospitals (79%) in 15 out of 26 states (9 states do not have stroke centers). The EMS covers 96% of the stroke centers but only 63% is linked with the local network. The centers are 34% public, 42% private and 24% assist both public and private patients (58% assist public health system). The stroke units are present in 49% of hospitals. Neurologists are available 24h /7 days a week in 82% of the hospitals (33% on duty, 44% on call and 23% by telemedicine). In total, 41% of hospitals are comprehensive stroke centers. As the thrombectomy devices are not paid in the public hospitals, only 2 are comprehensive stroke centers, 8 had structure but not devices and are participating in a clinical trial to approve thrombectomy in public hospitals in Brazil. Conclusion: The organization of stroke care in Brazil has improved a lot in recent years. Despite this, we have a lot to improve, since it’s still a small number of hospitals for a huge country, with large part of its population without access to the best treatments.

Assessing the Fruitfulness of Defense Analysis in brief Focal Psychotherapy in the Intervention of Marital Therapy

The psychoanalytical approach in the couple patients becomes significant when the psychological parameters causing sufferings are unconscious. The technique, analysis of defense mechanisms is proven useful in understanding the unconscious roots of marital disturbances in gaining insight into problems. Thus the study objective focuses on analysis and interpretation of defenses, to find out the fruitfulness of defense analysis. This is a case study research design used for analyzing defense mechanisms used by patients in situational aspects of their life discussed in the clinical interview to find unconscious roots disturbing their marriage. Universal sampling was used for sample selection from Nitte psychiatry center, private patients and couples attended camps from 2007 to 2014. The intervention provided was brief focal psychotherapy, defense analysis and its interpretation was used as a tool for gaining insight into problems faced by the subjects in their marriage. There was high prevalence among patient couples who had unconscious roots in their past causing disturbances in their marriage. Of the 100 sample couples only 40 patient couple indicative for defense analysis and other 60 were excluded. Defense used by patient couple was interpreted to gain insight into problem behaviours thus improved interpersonal relationships among the marital couple. End of the intervention they were rated on 3 point scale measuring satisfaction levels that evaluate therapeutic success. More than 50% of sample population found to be highly satisfied and none of them spelt dissatisfaction. The collected data were presented with frequency and parentages, statistically analyzed by using Chi-square with Yates's correction test for association. The statistical software used is SPSS 20.00 version. The statistical significance was set at 5% level of significance (p<0.05).The present study has proven the hypothetical view that deeply rooted unconscious causes of marital disturbances among the patient couple shown its interventional success and fruitfulness of defense analysis.

Wireless Body Area Network Security and Privacy Issue in E-Healthcare

Wireless Body Area Network (WBAN) is a collection of wireless sensor nodes which can be placed within the body or outside the body of a human or a living person which in result observes or monitors the functionality and adjoining situations of the body. Utilizing a Wireless Body Area Network, the patient encounters a greater physical versatility and is never again constrained to remain in the hospital. As the Wireless Body Area Network sensor devices is being utilized for gathering the sensitive data and possibly will run into antagonistic situations, they require complicated and very secure security medium or structure to avoid the vitriolic communications within the system. These devices represent various security and privacy protection of touchy and private patient medical data. The medical records of patients are a significant and an unsolved situation due to which a changing or exploitation to the system is possible. In this research paper, we first present an overview of WBAN, how they utilized for healthcare monitoring, its architecture then highlight major security and privacy requirements and assaults at different network layer in a WBAN and we finally talk about various cryptographic algorithms and laws for providing solution of security and privacy in WBAN.

Comparative efficacy and acceptability of antiepileptic drugs for classical trigeminal neuralgia: a Bayesian network meta-analysis protocol

IntroductionTrigeminal neuralgia (TN) affects 4 to 28.9/100 000 people worldwide, and antiepileptic drugs such as carbamazepine and oxcarbazepine are the firstline treatment options. However, the efficacy and safety of other...

Long-term survival of corneal transplants and visual outcomes among private patients of corneal surgeons in Metropolitan Manila (the Philippines)

PURPOSE: There are currently no published studies on the outcomes of keratoplasty in the Philippines. This study aimed to report graft survival rates at years 1, 3, and 5 after surgery, visual outcomes, and causes of graft failure among private patients of corneal surgeons in Metropolitan Manila receiving tissue from a single local eye bank in the period 2008-2012. &#x0D; DESIGN: Retrospective cohort, multicenter study.&#x0D; METHODS: POPULATION: Private patients of Metro Manila corneal surgeons, receiving tissue from the Santa Lucia International Eye Bank of Manila in 2008-2012. 241 of 593 yielded sufficiently complete data sets. PROCEDURE: Donor and tissue characteristics, pre-op and latest follow-up characteristics/clinical findings were retrieved and processed. Data from the eye bank was merged with follow-up data from surgeons submitted March-October 2014. MAIN OUTCOME MEASURES: Survival rates at 1, 3, and 5 years; best-corrected visual acuity as of latest follow-up; causes of failure.&#x0D; RESULTS: 1-year survival: 90.4%, 3-year: 71.5%, 5-year: ~52.7%. Overall, 43.5% had VA of 20/50 or better, and 25% counting fingers or worse, with variations across diagnoses.&#x0D; CONCLUSION: Though small in sample size and response rate, survival trends parallel studies with larger populations elsewhere. Specific trends like favorable survival in keratoconus were consistent. Indications for surgery have changed little since 2005, but regraft has become the most common indication. Further data collection and completion are required for multivariate analysis on factors regarding survival. Inflammation, infection, trauma, poor adherence are among the identified reasons for failure.&#x0D;

Examining the high users of hospital resources: implications of a profile developed from Australian health insurance claims data.

Objective To develop and examine a profile of the demographic, hospital admission and clinical characteristics of high users of hospital resources within a cohort of privately insured Australians. Methods Hospital admissions claims data from a group of private health insurance funds were analysed. The top 1% of hospital users were selected based on three measures of resource utilisation: number of admissions, total bed days and total insurance benefits paid. The demographic, hospital admission and clinical characteristics data were compared for these three measures of resource utilisation. Results Compared with the general insured population, the three high-use cohorts are older, have more public hospital admissions and have more same-day admissions. The three high-use cohorts have the same top five principal diagnosis categories. These five categories account for more than two-thirds of admissions. The top 1% of users is responsible for a large proportion of total resource utilisation, accounting for 13% of total costs and 21% of total bed days. Conclusions The highest users of hospital resources have a distinct profile, accounting for a large proportion of total resource utilisation for a narrow range of health conditions. The age and hospital admission profile of this group suggest both policy and service considerations for the targeting of interventions to support this high-needs group. What is known about this topic? Statistics are regularly published on the uptake and use of private health insurance in Australia but there is little detailed information on resource utilisation in specific subgroups, particularly those with the highest levels of hospitalisation. What does this paper add? This paper provides a profile of high resource utilisation among a privately insured cohort, describing demographic, hospital admission and clinical characteristics across three measures of resource utilisation. Patterns of use are detailed in this profile, for example the top 1% of users have a higher proportion of public hospital admissions as a private patient. The clinical profile of admissions was similar for the three measures of resource utilisation and there was considerable overlap in the individuals categorised in each high-use group. What are the implications for practitioners? The narrow demographic and clinical profile of the high resource utilisation groups shows a chronic disease burden that is different to the focus of current chronic disease policy measures. The high-use conditions identified in this study are less amenable to preventive measures and new strategies may be required to target this high-needs group.

Seguridad de la histeroscopia oficinal en una unidad de fertilidad. Bogotá, Colombia, 2011-2016. Cohorte retrospectiva

Objetivo: describir los hallazgos, el nivel de dolor y las complicaciones de la histeroscopia oficinal en el estudio de la paciente infértil. Materiales y métodos: cohorte retrospectiva de mujeres sometidas a histeroscopia oficinal por historia de falla de implantación, con estudio ecográfico previo normal, entre enero de 2011 y marzo de 2016, en una unidad de fertilidad que atiende pacientes particulares y de medicina prepagada. Se excluyeron las pacientes que no continuaron seguimiento en esta institución. Muestreo consecutivo. Se evaluaron variables sociodemográficas, clínicas, hallazgos intraoperatorios, causas de cancelación, nivel de dolor, complicaciones intraoperatorias o posoperatorias. Se realizó análisis descriptivo. Resultados: de un total de 195 pacientes que cumplieron los criterios de selección se incluyeron 171. Se excluyeron 24 pacientes que no terminaron su tratamiento en esta Unidad. Las pacientes incluidas tenían una mediana de edad de 40 años (RIQ 36-43 años); de ellas, el 86 % nulíparas, y 42 % con diagnóstico de infertilidad primaria, 39 % secundaria y 20 % terciaria. En el 59 % de los casos se encontraron alteraciones endometriales. En el 7,6 % se encontró más de un hallazgo patológico. Hubo una frecuencia de complicaciones de 3 % (dolor y efecto vasovagal), sin complicaciones mayores, y una frecuencia de cancelación de 8 %. Conclusiones: la HSC oficinal con abordaje vaginoscópico es un procedimiento seguro, con buena tolerancia, seguridad y con bajo riesgo de complicaciones a corto y largo plazo.

Asthma hospitalisation trends from 2010 to 2015: variation among rural and metropolitan Australians

BackgroundAsthma remains a leading cause of illness, where primary care can assist to reduce hospitalisations through prevention, controlling acute episodes, and overall management of asthma. In Victoria, Asthma hospitalisations were as high as 3.1 hospitalisations per 1000 population in 1993–94. The primary aims of this study are to: determine if changes in asthma hospitalisations have occurred between 2010 and 2015; determine the key factors that impact asthma hospitalisation over time; and verify whether rural and urban asthma hospitalisations are disparate. A secondary aim of the study is to compare 2010–2015 results with asthma data prior to 2010.MethodsHospital separation data from 1 July 2010 to 30 June 2015 were obtained through the Victorian Admitted Episodes Dataset and other agencies. Data included sex, age, Local Government Area, private or public patient, length of stay, and type of discharge. Asthma and predictor variables were analysed according to hospital separation rates after adjusting for smoking and sex. Hierarchical multiple regression examined the association between asthma and predictor variables.ResultsDuring the study period, 49,529 asthma hospital separations occurred, of which 77.5% were in metropolitan hospitals, 55.4% hospital separations were aged 0–14 years, and 21.7% were privately funded. State-wide hospital separations were 1.85 per 1000 population and were consistently higher in metropolitan compared to rural areas (1.93 vs 1.64 per 1000 population). When data among metropolitan adults aged 15 and over were analysed, an increase in the proportion of smokers in the population was reflected by an increase in the number of hospital separations (Adj OR 1.035). Further, among rural and metropolitan children aged 0–14 the only predictor of asthma hospital separations was sex, where metropolitan male children had higher odds of separation than metropolitan females of the same age (Adj OR 4.297). There was no statistically meaningful difference for separation rates between males and females in rural areas.ConclusionsWe demonstrated a higher overall hospital separation rate in metropolitan Victoria. For children in metropolitan areas, males were hospitalised at higher rates than females, while the inverse was demonstrated for children residing in rural areas. Therefore, optimising asthma management requires consideration of the patient’s age, gender and residential context. Primary health care may play a leading role in increasing health literacy for patients in order to improve self-management and health-seeking behaviour.

Use of Game Theory to model patient engagement after surgery: a qualitative analysis

BackgroundPatient engagement is challenging to define and operationalize. Qualitative analysis allows us to explore patient perspectives on this topic and establish themes. A game theoretic signaling model also provides a framework through which to further explore engagement. MethodsOver a 6-mo period, thirty-eight interviews were conducted within 6 wk of discharge in patients undergoing thyroid, parathyroid, or colorectal surgery. Interviews were transcribed, anonymized, and analyzed using the NVivo 11 platform. A signaling model was then developed depicting the doctor-patient interaction surrounding the patient's choice to reach out to their physician with postoperative concerns based upon the patient's perspective of the doctor's availability. This was defined as “engagement”. We applied the model to the qualitative data to determine possible causations for a patient's engagement or lack thereof. A private hospital's and a safety net hospital's populations were contrasted. ResultsThe private patient population was more likely to engage than their safety-net counterparts. Using our model in conjunction with patient data, we determined possible etiologies for this engagement to be due to the private patient's perceived probability of dealing with an available doctor and apparent signals from the doctor indicating so. For the safety-net population, decreased access to care caused them to be less willing to engage with a doctor perceived as possibly unavailable. ConclusionsA physician who understands these Game Theory concepts may be able to alter their interactions with their patients, tailoring responses and demeanor to fit the patient's circumstances and possible barriers to engagement.

Factors associated with women’s intention to request caesarean delivery in Dar es Salaam, Tanzania

Background. In the past decade, the rate of caesarean section (CS) has increased dramatically in many parts of the world. At Muhimbili National Hospital (MNH) there has been a dramatic rise in the caesarean section rate over the past decade. Objective . To determine the incidence of maternal request for CS and factors associated with intention to request caesarean section at the MNH antenatal clinic. Methods . We conducted a cross-sectional study from August to October 2014. A structured questionnaire gathered participants’ background and obstetric information, perceptions and opinions regarding a request for caesarean section, and the respective reasons for the request. Confidence intervals were calculated and a p- value <0.05 was considered significant. Results . The incidence of CS on maternal request was about 6%. The intention to request for CS in the index pregnancy was 8%. Higher-level education and formal-sector employment had higher odds for requesting CS ( p =0.01 and p =0.05, respectively). Half of the participants agreed that maternal request for CS should be allowed; more private patients agreed that it could affect the doctor-patient relationship ( p =0.02); more private patients agreed that request for CS was due to fear of losing a child ( p =0.03). Previous history of CS was an independent predictor of maternal request for caesarean section (OR 1.7; 95% CI 1.7 - 15.4) and (OR 5.8; 95% CI 1.6 - 20.1), respectively. Conclusion . Maternal requests for CS exist at the national referral hospital in Tanzania. This was associated with factors other than women’s preferences, including perceived fear of child loss and events associated with previous CS.

Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry

It is poorly understood whether insurance type may be a major contributor to the underuse of oral anticoagulation (OAC) among patients with atrial fibrillation (AF), particularly for novel oral anticoagulants (NOACs). We performed a retrospective cohort registry study of patients with insurance, AF, CHA2DS2-VASc ≥2, and at least one outpatient encounter recorded in the ACC NCDR's PINNACLE Registry between January 1, 2011 and December 31, 2014. We used hierarchical regression, adjusting for patient characteristics and clustering by physician, to evaluate the association of insurance type (Private, Military, Medicare, Medicaid, Other) with receipt of OAC (any OAC, warfarin, or NOAC). In 363,309 patients (age 75±10; 48% female), we found a significant difference in proportions of OAC and NOAC prescription across insurance types (OAC: Military 53%, Private 53%, Medicare 52%, Other 41%, Medicaid 41%, P<.001; NOAC: Military 24%, Private 19%, Medicare 17%, Other 17%, Medicaid 8%, P<.001). After adjustment for patient characteristics and facility, private, Medicaid, and other insurance were independently associated with a lower odds of OAC prescription relative to Medicare, but military insured patients were not significantly different. After adjustment, military and private insurance were independently associated with a higher odds of NOAC prescription relative to Medicare, while Medicaid and other insurance were associated with a lower odds of NOAC prescription. In a contemporary US AF population, there was significant variation of OAC prescription across insurance plans, with the highest among private and Medicare insured patients. These differences may indicate that insurance plan, and its associated pharmacy benefits, affect the pace of diffusion of new therapies.

Disparities in Breast Cancer: Private Patients Have Better Outcomes Than Public Patients.

Different outcomes in breast cancer have been reported for low and high socio-economic groups. We present data quantifying disparities between South African public and private patients. Records of 240 consecutive patients treated in 2008 in a public versus 97 patients in a private health facility were reviewed for demographic and oncologic data. The average of patients was 56.2 versus 51.9years (p=0.032). Stage at presentation was 0 in 0.83 versus 25.8%, I in 4.5 versus 15.5%, II in 41.3 versus 37.1%, III in 37.1 versus 18.6% and IV in 16.3 versus 3.1% public versus private patients. Seventy-three percent of patients were symptomatic versus 57.7%. Of patients with stage 0-III disease, 17.9 versus 20% had simple tumour excision and 7.5 versus 14%, oncoplastic tumour excision. The mastectomy rate was similar (52 vs. 60%), but immediate reconstruction was performed in 10 versus 63%. Public patients were less likely to have radiotherapy. The pathology was similar, 27.2 versus 20, 54 versus 52, 87 versus 61% of patients with stage I, II and III disease, respectively, had chemotherapy. Hormonal therapy for premenopausal patients in private was a LHRH agonist in 9.3%, ovarian ablation/BSO in 11.7% of public patients; biologicals were given in 7.2 versus 0% of patients. Overall survival for public versus private was 66 versus 80% (p<0.001) months. Better per stage survival of private patients 100 versus 100, 72.7 versus 93.3, 84.8 versus 88.9, 57.3 versus 77.8 and 33 versus 33% for stages 0, I, II, III and IV, did not reach statistical significance. The greatest impact on outcome was stage at presentation, but more aggressive therapy for each stage resulted in a trend to better outcome for private patients.