Is health insurance in Greece in need of reform?
This paper aims to assess the relationship between insurance contributions and health benefits in Greece by using information from sickness funds' accounts. The paper argues that the fragmentation of social health insurance, and the particular ways in which sickness funds' financial services are organized, are a major source of inequity and are grossly inefficient. The survival of these systems in the 1990s cannot be explained except on grounds of inertia and corporate resistance. (+info)
Use of an east end children's accident and emergency department for infants: a failure of primary health care?
OBJECTIVE: To ascertain why parents use an accident and emergency department for health care for their infants. DESIGN: Prospective one month study. SETTING: One accident and emergency department of a children's hospital in the east end of London. SUBJECTS: Parents of 159 infants aged < 9 months attending as self referrals (excluding infants attending previously or inpatients within one month, parents advised by the hospital to attend if concerned about their child's health, infants born abroad and arrived in Britain within the previous month). MAIN MEASURES: Details of birth, postnatal hospital stay, contact with health professionals, perceptions of roles of community midwife and health visitor, and current attendance obtained from a semistructured questionnaire administered in the department by a research health visitor; diagnosis, discharge, and follow up. RESULTS: 152(96%) parents were interviewed, 43(28%) of whom were single parent and 68(45%) first time mothers. Presenting symptoms included diarrhoea or vomiting, or both (34, 22%), crying (21, 14%), and feeding difficulties (10, 7%). Respiratory or gastrointestinal infection was diagnosed in 70(46%) infants. Only 17(11%) infants were admitted; hospital follow up was arranged for 27(20%) infants not admitted. Most (141, 94%) parents were registered with a general practitioner; 146(27%) had contact with the community midwife and 135(89%) the health visitor. CONCLUSION: Most attendances were for problems more appropriately dealt with by primary care professionals owing to patients' perceptions of hospital and primary health care services. IMPLICATIONS: Closer cooperation within the health service is needed to provide a service responsive to the real needs of patients. (+info)
Quality: link with effectiveness.
In summary, though the notion of "quality of care" has become fashionable, most of the focus has been on initiatives such as the patient's charter, waiting times, quality of the physical environment, patient centredness in outcomes measurement, etc. Nevertheless, at the heart of quality must be the effectiveness and cost effectiveness of interventions. Without ensuring that health technologies are effective and are delivered appropriately then many of the other dimensions of quality may simply be window dressing. Substantial variations in the rates of procedures, the way in which similar patients are treated, and the degree to which professionals often ignore the best scientific evidence have all been well documented. The NHS needs methods for ensuring that the effectiveness dimension of quality is brought to the fore and becomes a routine part of quality assessment and activity. Clinical autonomy can no longer be an excuse for inappropriate care. The challenge for the future is twofold: to increase the amount of health technology assessment carried out and to develop methods of ensuring that health care converges with this best practice--that is, the promotion of evidence based practice. By introducing evidence based clinical guidelines and associated utilisation review and persuading purchasers to "purchase protocols" rather than just procedures the effectiveness dimension may become more routine, but it will require a radical rethink of the type of data collected and the way in which the purchaser provider split is managed. (+info)
Effect of a drug supply and cost sharing system on prescribing and utilization: a controlled trial from Nepal.
The effect on prescribing habits of a drug supply and cost sharing system was studied in a hill district in Nepal. In this district the inadequate yearly supply of drugs from the government was supplemented by an extra supply from the project. Drugs were sold at a fixed prescription charge which covered all drugs for one episode of illness. The prescribing pattern in this district was compared to a control district with only the yearly government drug supply and no drug scheme. Drugs prescribed were also compared to theoretical needs based on the recorded diagnoses of the same patients and recommended treatment guidelines. Attendance figures were studied before and after the introduction of the drug scheme in the test district. A 25% sample of prescriptions was taken from all health posts in both districts, over a one year period. This was in total 11,772 prescriptions from 22 health posts. The results show that in the drug scheme district health workers prescribed essential drugs excessively. However, the doses that were prescribed were somewhat better than in the control district. Utilization of health facilities dropped by 18% in the drug scheme district and then increased in the second year. A supply of essential drugs does not necessarily improve the quality of care, or increase attendance levels. The WHO indicators designed to assess the quality of drug use at health facilities can give a misleading picture, as they do not include information on dosages. The effect on quality of care of supply and financing mechanisms needs further study. (+info)
Aspirin treatment after myocardial infarction: are health maintenance organization members, women, and the elderly undertreated?
In April 1996, we surveyed 539 patients who had suffered a myocardial infarction in 1995 to determine whether the prescription and use of aspirin after myocardial infarction differs by patient age, sex, and type of health insurance. Patients who were insured through one of four health maintenance organizations in major metropolitan areas or by an indemnity plan in 40 states completed the survey. Among the 502 patients with no contraindications to use, 93.8% were prescribed aspirin. Among patients with a prescription and no subsequent contraindications to use, 96.4% were taking aspirin when surveyed. Among aspirin users, 96.5% reported taking aspirin daily. Controlling for other characteristics, 75-year-old patients were 5 percentage points less likely to receive a prescription for aspirin than were 50-year-old patients (P = 0.05). Although not significant at conventional levels, point estimates revealed a prescription rate for women that was 6 percentage points higher than that for men (P = 0.054) and a rate for health maintenance organization members that was 4 percentage points lower than that for patients with indemnity insurance (P = 0.10). Aspirin use was lower among older patients (P = 0.02) but did not differ by gender or type of insurance plan. Health maintenance organization members were just as likely to receive a prescription from a specialist as were those with indemnity insurance (P = 0.92). Based on these results, the rate of aspirin treatment after myocardial infarction may be much higher than previous studies indicate. Concerns that managed care patients and women may be undertreated are not supported by our findings. Although older patients are at risk for undertreatment, this risk is low. Once aspirin is prescribed, selfreported patient compliance with a daily regimen of aspirin is high. (+info)
Effect of insurance coverage on the relationship between asthma hospitalizations and exposure to air pollution.
OBJECTIVE: Based on the assumption that people without health insurance have limited access to the primary care services needed to prevent unnecessary hospitalizations for asthma, the authors hypothesized that insurance is a factor in the strength of the association between hospital admissions for asthma and exposure to air pollution. They tested this hypothesis with 1991-1994 data from central Los Angeles. METHODS: The authors analyzed the effect of insurance status on the association between asthma-related hospital admissions and exposure to atmospheric particulates (PM10) and ozone (O3) using hospital discharge and air quality data for 1991-1994 for central Los Angeles. They used regression techniques with weighted moving averages (simulating distributed lag structures) to measure the effects of exposure on overall hospital admissions, admissions of uninsured patients, admissions for which MediCal (California Medicaid) was the primary payer, and admissions for which the primary payer was another government or private health insurance program. RESULTS: No associations were found between asthma admissions and O3 exposure. An estimated increase from 1991 to 1994 of 50 micrograms per cubic meter in PM10 concentrations averaged over eight days was associated with an increase of 21.0% in the number of asthma admissions. An even stronger increase--27.4%--was noted among MediCal asthma admissions. CONCLUSIONS: The authors conclude that low family income, as indicated by MediCal coverage, is a better predictor of asthma exacerbations associated with air pollution than lack of insurance and, by implication, a better predictor of insufficient access to primary care. (+info)
The role of medical problems and behavioral risks in explaining patterns of prenatal care use among high-risk women.
OBJECTIVE: To examine the associations between maternal medical conditions and behavioral risks and the patterns of prenatal care use among high-risk women. DATA SOURCE/STUDY DESIGN: Data on over 25,000 high-risk deliveries to African American and white women using multinomial logistic regression to predict the odds of adequate-plus care relative to three other categories of care. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from records maintained by the University of Florida/Shands Hospital maternity clinic on all deliveries between 1987 and 1994; records for white and for African American women were subset to examine racial differences in medical conditions, health behaviors, and patterns of prenatal care use. PRINCIPAL FINDINGS: Net of sociodemographic and fertility-related characteristics, African American and white women with late antepartum conditions and hypertension problems had significantly higher odds of receiving adequate-plus care, as well as no care or inadequate care, relative to adequate care. White women with gynecological disease and medical/surgical problems were significantly less likely to receive no care or inadequate care, as were African American women with gynecological disease. CONCLUSIONS: Maternal medical conditions explain much but not all of the adequate-plus prenatal care use. More than 13 percent of African American women and 20 percent of white women with no reported medical problems or behavioral risks used adequate-plus care. Additional research is needed to understand this excess use and its possibilities in mediating birth outcomes. (+info)
Responding to out-of-hours demand: the extent and nature of urgent need.
BACKGROUND: Little research has been undertaken concerning GPs' perceptions about urgent or 'appropriate' out-of-hours demand. OBJECTIVE: We aimed to measure GPs' perceptions about patients' need for urgent out-of-hours general medical help according to indicators of physical, psychological/emotional and social need, and the medical necessity of a home visit. METHODS: Twenty-five practices participated in an audit and research study whereby GPs completed an audit form for all contacts during November/December 1995 and February/March 1996. Each contact was assessed according to the indicators of urgent need and GPs commented on reasons for making such assessments. RESULTS: Audit forms were completed on 1862 patients, and GPs considered that 66.6% (1027) of contacts had either a physically, psychologically/emotionally or socially urgent need for help and were uncertain about a further 10.7% (165). Over half (53.0%) were considered to have an urgent physical need, almost one-third (31.0%) to have an urgent psychological/emotional need and 10.1% (119) to have an urgent social need for help. Over half (55.2%) of visits were considered to be medically necessary, the majority of which (89.9%) were assessed as having an urgent physical need for help. CONCLUSIONS: The findings raise questions about the strategic direction of newer forms of service delivery (GP Co-operatives) and suggest the need for further research to inform the strategic reduction in home visiting, particularly in inner-city areas where many residents have little access to transport out-of-hours to enable them to attend a primary care centre. GP co-operatives are, however, well placed to improve interagency working and cross-referral to other health and social service personnel, and respond more 'appropriately' to some psychological/emotional and social problems. (+info)