Variation In Provision Research Articles

Colon cancer treatment in rural North and South Carolina.

The purpose of this study was to determine the degree to which colon cancer treatment in rural North and South Carolina in 1991 and 1996 conformed to national treatment recommendations. Data came from medical records of colon cancer patients residing in rural North and South Carolina. The National Cancer Institute's Physician Data Query (PDQ) database was used to define state-of-the-art care and to categorize receipt of primary and/or adjuvant treatment. Changes in treatment over time, location, and stage and bivariate relationships between treatment and selected covariates were assessed with chi-square and Fisher's exact tests. Regression was used to control for possible interactions between patient and/or disease characteristics and treatment. The majority of colon cancer cases received primary therapy as suggested by the PDQ which was not significantly related to other factors examined. There was variation in provision of adjuvant therapy. Stage III patients received adjuvant therapy significantly more often than did stage II patients (p </= 0.01). Receipt of appropriate adjuvant therapy among stage III patients was significantly associated with younger patient age and white race (p </= 0.05). Rural colon cancer patients are likely to receive primary therapy as recommended by the PDQ, but may be less likely to receive suggested adjuvant therapy. Further understanding of variations in the rate of adjuvant therapy for colon cancer is needed to ensure appropriate treatment regimens are obtained for rural colon cancer patients.

The Funding Agencies' Perspective on the Provision of Electronic Assistive Technology: Equipping for Life?

Electronic assistive technology (EAT) — powered wheelchairs, communication equipment and environmental control systems — can greatly improve the user's and carers' quality of life if prescription is timely and appropriate. Despite the benefits that this equipment can bring, the provision of EAT is a highly confused area because different funding agencies with different remits are involved. As part of a larger research project, a survey was carried out to investigate the remit of and the range of equipment supplied through three funding sources within a given geographical area. This paper gives the results of this survey and presents a snapshot of provision, showing the differences that can occur. It was found that a wide range of equipment was available through these agencies but that the variation in provision was great. Provision was affected adversely by differences in eligibility criteria, referral mechanisms and funding management. The paper concludes that professionals working in this field should be aware of the level of services provided by all agencies throughout their areas. Solutions such as the Joint funding of equipment are suggested for users who live in areas with services that have stringent criteria and are hence perhaps denied the independence that they could achieve.

Organization of old age psychiatry services

In the last review on this topic for this journal the focus was mainly upon service principles and an overview of variation in provision around the world. While there have been important developments and challenges within old age psychiatry in the last five years, these fundamental principles remain valid. This paper will therefore not simply present an updated version of the last but will instead concentrate on specific issues which seem to be of particular salience in the consideration of the organization and delivery of old age psychiatry services.

Why is mortality higher in poorer areas and in more northern areas of England and Wales?

STUDY OBJECTIVE: To identify and quantify the factors responsible for the differences in mortality between affluent and deprived areas, the north and the south, and urban and rural areas in...

Cardiac rehabilitation in Scotland: is current provision satisfactory?

Cardiac rehabilitation is an effective intervention, lowering mortality following myocardial infarction and reducing morbidity in patients with coronary heart disease. However, its level of provision was unclear. This study aimed to provide a comprehensive description in Scotland. A national survey of hospital, general practice and community sources was conducted in 1994 to identify cardiac rehabilitation programmes in Scotland. Detailed information about each programme was collected by computer-assisted telephone interviews. Sixty-nine programmes were identified, providing out-patient cardiac rehabilitation to 4980 patients and in-patient cardiac rehabilitation to 8920 patients. This represented 17 per cent and 30 per cent of patients admitted to hospital with coronary heart disease (excluding heart failure), respectively. There was considerable geographical variation in provision and dependence on sources outside the health service for much funding. Despite evidence of benefits from randomized trials, the overall provision of cardiac rehabilitation in Scotland was low. Considerable inequity was demonstrated between different health board areas. There is opportunity for better provision, which would improve care for many patients with coronary heart disease.

Variation in purchasing for the invasive management of coronary heartdisease

This paper reports the results of a postal questionnaire survey of Directors of Public Health in all health authorities in the United Kingdom (as at March 1994). Our aim was to examine variations in the purchasing of coronary artery bypass grafting, percutaneous transluminal coronary angioplasty and coronary angiography. Information on planned service developments in cardiology was also sought. The response rate was 62%. The mean rate of CABG was 374 per million total population (range 162–710); PTCA 183 (range: 18–648); and coronary angiography 1,010 (range 581–2,334). The mean ratio of invasive treatment to angiography was 1 : 2. Variations in provision were not related to mortality from coronary heart disease or the availability of a local provider. Those districts purchasing higher levels of CABG tended to purchase higher levels of PTCA (Spearman's r=0.52). Observed variations in purchasing of invasive treatments and investigation for coronary heart disease do not relate to population ‘need’ as defined by mortality rates from CHD. The greatest variations are seen in the purchasing of PTCA, an intervention whose place in the management of CHD is as yet not fully defined. Consensus guidelines on the appropriate use of these interventions and on population needs are required.

Geographic variation in utilization of cataract surgery.

Cataract surgery is the most frequently performed surgical procedure on Medicare beneficiaries, with an annual cost to the Medicare program of more than $3.4 billion. In this study, the relationship between demographic, environmental, and provider-related factors, and the likelihood that cataract surgery will be performed on a Medicare beneficiary were assessed. The association between likelihood of cataract surgery and patient age, sex, race, income, and latitude of residence was examined, as was the association with the supply of ophthalmologists and optometrists in each region, and the allowed charge for cataract surgery and cost of practice in a region. This cross-sectional, population-based study used administrative data. Both regional models, using least-squares regression and person-based models, using logistic regression were employed. A random 5% sample of 1986 and 1987 Medicare beneficiaries, 65 years of age and older, were included in the study. Medicare beneficiaries who lacked continuous Part A and Part B coverage during 1986 and 1987, or who were enrolled in a health maintenance organization at any time during this 2-year period of observation were excluded from the study to make certain that complete utilization data were available for each individual. Rate of cataract surgery per 1,000 Medicare beneficiaries in each Bureau of Economic Analysis Economic Area (BEAEA) and the likelihood of an individual with particular characteristics undergoing cataract surgery were determined in separate regression models. The mean annual rate of cataract surgery during 1986 and 1987 in the 181 BEAEAs was 25.4 surgeries per 1,000 persons 65 years of age or older (standard deviation = 6.2, coefficient of variation = 0.24). Both the regional model and the person-based model detected an association between a higher rate of and personal likelihood of cataract surgery and female gender, more southerly latitude, higher concentration of optometrists per 1,000 Medicare beneficiaries, and higher allowed charge for cataract surgery, after adjusting for variation in practice expense. The person-based model additionally demonstrated that increased likelihood of undergoing cataract surgery was associated with increasing age from 65 to 94 years, white race, and living in a zip-code area with mean income greater than $15,000. Neither analysis detected a statistically significant association between the concentration of ophthalmologists per 1,000 Medicare beneficiaries and the regional rate of, or an individual's likelihood of, cataract surgery. Compared with the geographic variation in provision of other surgical procedures, the variation in cataract surgery across large geographic areas observed in this analysis was relatively low.(ABSTRACT TRUNCATED AT 400 WORDS)

Population need for renal replacement therapy in Thames regions: ethnic dimension

To determine the use of renal replacement therapy by ethnic origin and to ascertain the variation in provision of such therapy and to relate this to the distribution of ethnic minority populations. Analysis of retrospective and cross sectional data from 19 renal units. All four Thames regional health authorities. Patients resident in the Thames regions who were accepted as new patients for renal replacement therapy during 1991 and 1992 and the patients who were already undergoing such treatment between December 1992 and April 1993. Rates of acceptance for and prevalence of renal replacement therapy among white, black, and Asian people. The average annual acceptance rates per million in 1991-2 were 61 for white people, 175 for black people, and 178 for Asians, and the prevalences per million were 351, 918, and 957 respectively. The relative risks increased with age. A threefold increase in the acceptance rate occurred in people aged under 55 in both the black and Asian populations, suggesting that the higher rates are probably not due to factors related to access alone. Treatment rates varied considerably among districts, reflecting both the distribution of ethnic minority populations and access to services. Black and Asian people receive and have a greater need for renal replacement therapy, and the need will increase as these populations age. These findings have important implications for the provision of renal services in districts with a high proportion of ethnic minorities and for the management of diabetes mellitus and hypertension, two important causes of end stage renal failure in these populations.

A Survey of Approved Social Work in England and Wales

SUMMARY A survey of approved social workers (ASWs) was undertaken with local authorities in England and Wales, to review the provision and organization of ASW services, and the contribution they make towards the establishment and maintenance of a comprehensive mental health service. The findings show some variation in provision which is in itself indicative of a variety of factors operating to produce local and regional patterns of provision. Some of these are related directly to policy decisions, others to demographic and geographic variables, while still more are related to team structure, workload demands, and generic/specialist issues. The future pattern of mental health social work following the implementation of the NHS and Community Care Act is considered in the light of the findings from the survey. Under section 114 of the Mental Health Act, 1983, local authorities are required to appoint a sufficient number of approved social workers (ASWs) to carry out the functions given to them by the Act. The Act enhanced the role of the ASW and stimulated many local authorities towards investing resources into the training and approval of ASWs. The goal of having ASWs as an integral part of a comprehensive mental health service, offering assessment, care and treatment, and discharging their statutory powers in an informed and responsible manner has been hard to achieve for some authorities. The task involves the determining of clear principles and policies to underpin and guide service delivery, familiarity with geographic and demographic data (particularly with regard to minority groups), the ability to calculate the resources needed to meet the requirements of section 114, and sufficient negotiation and liaison skills to work as part of a multidisciplinary team. Selection and

A study of the provision of health checks and health‐promotion clinics in 18 general practices

Summary The objective of this study was to describe the variation in provision of health checks and health‐promotion clinics operating under the regulations of the 1990 Contract for general practice in the UK. Eighteen group practices in three Family Health Service Authority (FHSA) areas of England (two in the South West Thames region and one in the Yorkshire region) were selected for the study. The nurses, largely responsible for the implementation of the health checks at these practices, were interviewed using semi‐structured interview schedules. They were asked about age‐groups targeted, means of recruiting patients for clinics, duration of clinic appointments, and procedures carried out in clinics. All practices offered health checks, and 55% had started doing so before introduction of the 1990 Contract. Recruitment for health checks took place in a number of ways: self‐referral (83% of practices); opportunistically in those with coronary heart disease risk factors (78%); opportunistically during attendance for cervical smears (62%); screening in at least one patient group (78%). Blood pressure, height, weight, urinalysis and life‐style advice were included by all practices. Stress management and quit smoking strategies were offered only by a minority of practices. Duration of first health‐check appointment ranged between 15 and 30 minutes. The basic content of health checks, and life‐style advice given appeared consistent between the widely varying practices. However, the resources available for intervention and follow up showed more variation.

Gynaecologists' abortion practice.

To ascertain the relation between gynaecologists' opinions on the provision of abortion and the service provided by the Health Service in their district and to investigate the methods used for second trimester abortion. A postal questionnaire sent three times to a 50% random sample of gynaecologists practising in the National Health Service (NHS) in 1989 in Great Britain. 343 of 396 practising gynaecologists, 87% of those selected. Proportion of gynaecologists holding views or reporting practice. Although only 11% actually performed abortions beyond 20 weeks, 57% approved later operations in cases of rape and 85% for a threat to the woman's health; only 47% approved late abortion for schoolgirls under 16 years. Dilatation and evacuation was used by only 1% of NHS gynaecologists even though from 13 to 16 weeks it is a safe and efficient method. Although Government statistics report that vacuum aspiration is used in over one third of second trimester abortions, this is technically unlikely and was not confirmed by this study. Less than 50% of abortions in England and Wales are performed in the NHS yet fewer than 40% of gynaecologists reported problems in providing an abortion service. Overall 21% thought they were providing abortions for over 90% of the women resident in their districts, whereas only 2% of districts achieve this proportion in their home regional health authority. Overall 60% supported separating abortion work from general gynaecology, and 45% would like regional abortion units. Only 27% supported fertility control acquiring the status of a subspecialty. Accepting these suggestions would improve the service, reduce regional variations in provision, provide opportunities for research and could have an important effect in helping slow the world population increase.

11 Variations in provision and uptake of antenatal care

Antenatal care providers vary from one country to another. In Europe, most of the care is provided by obstetricians in some countries, while the role of midwives is important in other countries. Many women are attended by general practitioners in Canada and, to a lesser extent, in the US. Involvement of traditional birth attendants in antenatal care in more than 5% of the pregnancies has been reported in Guatemala, Honduras and Mexico only. Several indicators may be used to measure the utilization of antenatal care: the percentage of women receiving care, timing of the first visit, proportion of women receiving late or no care, number of visits and indexes of adequacy of antenatal care. Recent world data are provided. The percentage of women receiving antenatal care is higher than 90% in many countries, including some developing countries. However, the proportion of women with late or no care is increasing in the US. Women of low sociodemographic status are at high risk of having inadequate care. Financial barriers play a major role. Inadequate system capacity, distance, long waiting time, lack of child care and differences in culture, attitude and knowledge are other important barriers. Improving the services and outreach of non-participating women may both increase the utilization of antenatal care. Overutilization should also be a matter of concern. It could be better addressed by decreasing the recommended number of visits than by requesting payment of a part of the costs by the users.

The Politics of Location: An Introduction

This book, originally published in 1982, begins with an examination of space, and its role in the process of public provision and collective consumption. Variations in provision are linked to the Weberian notion of social status and political struggles over consumption and externality issues. Health care and education are considered in spatial contexts, and the whole basis of the electoral system is also discussed together with geographic underpinnings. In each case emphasis is placed on the jurisdictional organization of space by public bodies. The author examines the various examples of spatial cleavages, in which political events are redirected by issues such as nuclear power, airport location, road construction and urban renewal.