Relationships between various attitudes towards self-determination in health care with special reference to an advance directive.
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OBJECTIVES: The subject of patient self-determination in health care has gained broad interest because of the increasing number of incompetent patients. In an attempt to solve the problems related to doctors' decision making in such circumstances, advance directives have been developed. The purpose of this study was to examine relationships between public attitudes towards patient autonomy and advance directives. SUBJECTS AND MAIN OUTCOME MEASURES: A stratified random sample of 600 adults in northern Sweden was surveyed by a questionnaire with a response rate of 78.2%. The subjects were asked about their wish for control of their health care, their concerns about health care, their treatment preferences in a life-threatening situation (both reversible and irreversible), and their attitudes towards the application of advance directives. RESULTS: Numerous relationships between various aspects of self-determination in health care (desire for control, fears of over-treatment, and choice of treatment level) in general and advance directives, in particular, were found. Those who wanted to have a say in their health care (about 94%) also mainly supported the use of an advance directive. CONCLUSIONS: The fact that almost 30% of the respondents were undecided concerning their personal use of advance directives points to a lack of knowledge and to the necessity of education of the public on these issues. (+info)
Women patients' preferences for female or male GPs.
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OBJECTIVE: We aimed to investigate general preferences to see a male or female GP either some or all of the time, and specific preferences to see a female primary health care (PHC) worker for individual health issues; to compare these preferences with reported consultation behaviour; and to explore women's evaluations of the quality of PHC services in relation to their preferences and consultation behaviour. METHOD: Results are reported on 881 women aged 16-65 years who had consulted their GP in the previous 6 months. Logistical regression analysis was undertaken to evaluate whether a general preference to see another woman is more important than specific women's health issues in determining why some women regularly choose to consult a female GP. RESULTS: General preference was 2.6 times more important than specific health issues in predicting choice of a female GP in a mixed-sex practice. Nearly a half (49.1 %) of women attending male-only practices stated that they wanted to see a female GP in at least some circumstances, compared with 63.8% of women in mixed-sex practices. In total, 65.5% of the sample stated that there was at least one specific health issue for which they would only want to be seen by a woman PHC worker. The most positive evaluations of the quality of GP services were made by women normally seeing a male GP in mixed-sex practices and the least positive evaluations were given by women in male-only GP practices CONCLUSIONS: In order to meet women's expressed preferences, every GP practice should have at least one female GP available at least some of the time and every GP practice should employ a female PHC worker. (+info)
Why are workers uninsured? Employer-sponsored health insurance in 1997.
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This study examines the number of workers in firms offering employee health plans, the number of workers eligible for such plans, and participation in employer-sponsored insurance. Data from the February 1997 Contingent Worker Supplement to the Current Population Survey indicate that 10.1 million workers are employed by firms offering insurance but are not eligible. Not all of these workers are eligible for coverage, most often because of hours of work. Our results indicate that 11.4 million workers rejected coverage when it was offered. Of those, 2.5 million workers were uninsured. Workers cited high cost of insurance most often as the primary factor for refusing coverage. (+info)
Selection for oesophagectomy and postoperative outcome in a defined population.
(4/4015)
OBJECTIVE: To measure the extent of use of, and perioperative mortality from, oesophagectomy for carcinoma of the oesophagus, and to examine the association between oesophagectomy and long term survival. DESIGN: Retrospective cohort study of cases of oesophageal carcinoma notified to the Thames Cancer Registry. SETTING: South East Thames and South West Thames health regions. PATIENTS: 3273 patients first registered with carcinoma of the oesophagus during 1985-9, 789 of whom were excluded because of incomplete data, leaving 2484 (75.9%) for further analysis. MAIN MEASURES: Treatment of oesophagectomy, mortality within 30 days of oesophagectomy, and duration of survival from date of diagnosis to death, according to patient and tumour characteristics. RESULTS: Oesophagectomy was performed in 571(23.0%) patients. Its use decreased with increasing age (odds ratio (95% confidence interval) 0.935(0.925 to 0.944) per year) and was less common for tumours of the middle or upper third of the oesophagus than the lower third (0.56(0.42 to 0.75)). The proportion of patients undergoing oesophagectomy varied threefold among the 28 districts of residence. The perioperative mortality rate was 15.1(86/571) (12% to 18%); it increased with age (odds ratio 1.05(1.02 to 1.08) per year) and for tumours of the middle or upper third of the oesophagus compared with the lower third (2.52(1.31 to 4.84)). Long term survival was slightly higher for patients undergoing oesophagectomy (0.5% v 0.2%). CONCLUSIONS: Despite a high perioperative mortality rate patients selected for oesophagectomy showed better long term survival than those who were not, suggesting that clinical judgements used in selection were independent markers of a better prognosis. The nature of this selection needs to be more completely characterised to permit a valid evaluation of outcome of oesophagectomy. (+info)
Choice and accountability in health promotion: the role of health economics.
(5/4015)
Choices need to be made between competing uses of health care resources. There is debate about how these choices should be made, who should make them and the criteria upon which they should be made. Evaluation of health care is an important part of this debate. It has been suggested that the contribution of health economics to the evaluation of health promotion is limited, both because the methods and principles underlying economic evaluation are unsuited to health promotion, and because the political and cultural processes governing the health care system are more appropriate mechanisms for allocating health care resources than systematic economic analysis of the costs and benefits of different health care choices. This view misrepresents and misunderstands the contribution of health economics to the evaluation of health promotion. It overstates the undoubted methodological difficulties of evaluating health promotion. It also argues, mistakenly, that economists see economic evaluation as a substitute for the political and cultural processes governing health care, rather than an input to them. This paper argues for an economics input on grounds of efficiency, accountability and ethics, and challenges the critics of the economic approach to judge alternative mechanisms for allocating resources by the same criteria. (+info)
Medicare HMOs: who joins and who leaves?
(6/4015)
Medicare risk health maintenance organizations (HMOs) are an increasingly common alternative to fee-for-service Medicare. To date, there has been no examination of whether the HMO program is preferentially used by blacks or by persons living in lower-income areas or whether race and income are associated with reversing Medicare HMO selection. This question is important because evidence suggests that these beneficiaries receive poorer care under the fee-for-service-system than do whites and persons from wealthier areas. Medicare enrollment data from South Florida were examined for 1990 to 1993. Four overlapping groups of enrollees were examined: all age-eligible (age 65 and over) beneficiaries in 1990; all age-eligible beneficiaries in 1993; all age-eligible beneficiaries residing in South Florida during the period 1990 to 1993; and all beneficiaries who became age-eligible for Medicare benefits between 1990 and 1993. The associations between race or income and choice of Medicare option were examined by logistic regression. The association between the demographic characteristics and time staying with a particular option was examined with Kaplan-Meier methods and Cox Proportional Hazards modeling. Enrollment in Medicare risk HMOs steadily increased over the 4-year study period. In the overall Medicare population, the following statistically significant patterns of enrollment in Medicare HMOs were seen: enrollment of blacks was two times higher than that of non-blacks; enrollment decreased with age; and enrollment decreased as income level increased. For the newly eligible population, initial selection of Medicare option was strongly linked to income; race effects were weak but statistically significant. The data for disenrollment from an HMO revealed a similar demographic pattern. At 6 months, higher percentages of blacks, older beneficiaries (older than 85), and individuals from the lowest income area (less than $15,000 per year) had disenrolled. A small percentage of beneficiaries moved between HMOs and FFS plans multiple times. These data on Medicare HMO populations in South Florida, an area with a high concentration of elderly individuals and with one of the highest HMO enrollment rates in the country, indicate that enrollment into and disenrollment from Medicare risk HMOs are associated with certain demographic characteristics, specifically, black race or residence in a low-income area. (+info)
Determinants of patient choice of medical provider: a case study in rural China.
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This study examines the factors that influence patient choice of medical provider in the three-tier health care system in rural China: village health posts, township health centres, and county (and higher level) hospitals. The model is estimated using a multinomial logit approach applied to a sample of 1877 cases of outpatient treatment from a household survey in Shunyi county of Beijing in 1993. This represents the first effort to identify and quantify the impact of individual factors on patient choice of provider in China. The results show that relative to self-pay patients, Government and Labour Health Insurance beneficiaries are more likely to use county hospitals, while patients covered by the rural Cooperative Medical System (CMS) are more likely to use village-level facilities. In addition, high-income patients are more likely to visit county hospitals than low-income patients. The results also reveal that disease patterns have a significant impact on patient choice of provider, implying that the ongoing process of health transition will lead people to use the higher quality services offered at the county hospitals. We discuss the implications of the results for organizing health care finance and delivery in rural China to achieve efficiency and equity. (+info)
Contraceptive needs of women attending a genitourinary medicine clinic for the first time.
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OBJECTIVE: To assess the need for, and potential uptake of, a contraceptive service within a genitourinary medicine (GUM) clinic. METHODS: 544 women, median age 17 years (range 13-54) including 142 teenagers, attending the Fife GUM clinics serving a semirural population of 350,000 for the first time in the 12 month period from 1 September 1995 to 31 August 1996 were interviewed. RESULTS: Contraception was required by 353, of whom only 5% (29) were at risk of unplanned pregnancy, although half (15) of these were teenagers. 23 of 29 (79%) stated that they would access contraception at a GUM clinic if it were available. Of women using contraception, 67% (217/324) were taking the oral contraceptive pill (OCP), of whom 177 obtained supplies from their general practitioners and were happy with this. However, 92/177 (52%) stated that they would access the OCP at GUM clinics if it were available. Overall, of the 243 women who stated that they would access contraception at the GUM clinic, 23 of whom were currently at risk of an unplanned pregnancy, the demand was principally for condoms and the OCP. CONCLUSION: The majority of women attending GUM clinics for the first time are using contraception, or have deliberately chosen not to do so. Only 5% were at risk of unplanned pregnancy. In general, the women using contraception were happy with their current source of contraception, but about two thirds would use a contraceptive service at GUM clinics if it were available at the time they were attending the clinic. It was found that teenagers accounted for half of those women at risk of unwanted pregnancy. However, the majority of teenagers requiring contraception would consider obtaining it from GUM clinics. (+info)