(1/402) Where do people go for treatment of sexually transmitted diseases?
CONTEXT: Major public health resources are devoted to the prevention of sexually transmitted diseases (STDs) through public STD clinics. However, little is known about where people actually receive treatment for STDs. METHODS: As part of the National Health and Social Life Survey, household interviews were performed from February to September 1992 with 3,432 persons aged 18-59. Weighted population estimates and multinomial response methods were used to describe the prevalence of self-reported STDs and patterns of treatment utilization by persons who ever had a bacterial or viral STD. RESULTS: An estimated two million STDs were self-reported in the previous year, and 22 million 18-59-year-olds self-reported lifetime STDs. Bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) were more common than viral STDs (genital herpes, genital warts, hepatitis and HIV). Genital warts were the most commonly reported STD in the past year, while gonorrhea was the most common ever-reported STD. Almost half of all respondents who had ever had an STD had gone to a private practice for treatment (49%); in comparison, only 5% of respondents had sought treatment at an STD clinic. Respondents with a bacterial STD were seven times more likely to report going to an STD clinic than were respondents with a viral STD--except for chlamydia, which was more likely to be treated at family planning clinics. Men were significantly more likely than women to go to an STD clinic. Young, poor or black respondents were all more likely to use a family planning clinic for STD treatment than older, relatively wealthy or white respondents. Age, sexual history and geographic location did not predict particular types of treatment-seeking. CONCLUSIONS: The health care utilization patterns for STD treatment in the United States are complex. Specific disease diagnosis, gender, race and income status all affect where people will seek treatment. These factors need to be taken into account when STD prevention strategies are being developed. (+info)
(2/402) Potential savings from generic prescribing and generic substitution in South Africa.
Generic prescribing and generic substitution are mechanisms for reducing the cost of drugs. The purpose of this study was to assess the extent to which generic prescribing by private medical practitioners and generic substitution by private pharmacists is practised in South Africa and to estimate the potential savings from these two practices. Prescriptions from 10 pharmacists were collected on four randomly selected days. Computer printouts of all the prescriptions dispensed on these four days together with the original doctor's prescription were priced using a commercially available pharmacy dispensing computer package. A total of 1570 prescriptions with a total number of 4086 items were reviewed. Of the total prescriptions, 45.7% had at least one item for which there was a generic equivalent. Of the 961 drugs which had generic equivalents, 202 (21 %) were prescribed using the generic name of the drug. Only 0.3% of prescribers prohibited generic substitution. The cost of the prescription as dispensed was 1.4% (mean cost: R116.19 vs R117.84) below that of the original doctor's prescriptions, indicating the marginal benefit from the current low substitution rate of 13.9% by pharmacists. About 6.8% of the cost of the original doctor's prescriptions (mean cost: R117.84) could have been saved if total generic substitution (mean cost: R109.65) was practised. The cost of the prescriptions with only brand name items (mean cost: R120.49) would have been 9.9% higher than if generic drugs were used. Current restrictive prescribing and dispensing practices result in marginal cost savings from generic prescribing and generic substitution. Both these practices have a potential to reduce drug costs, if actively encouraged and practised to maximum capacity. It is noteworthy, however, that the potential savings from generic prescribing and substitution are at most 9.9% in the absence of any changes in types of drugs prescribed. (+info)
(3/402) Regulating the private health care sector: the case of the Indian Consumer Protection Act.
Private medical provision is an important constituent of health care delivery services in India. The quality of care provided by this sector is a critical issue. Professional organizations such as the Medical Council of India and local medical associations have remained ineffective in influencing the behaviour of private providers. The recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step towards regulating the private medical sector. This study surveyed the views of private providers on this legislation. They believe the COPRA will be effective in minimizing malpractice and negligent behaviour, but it does have adverse consequences such as an increase in fees charged by doctors, an increase in the prescription of medicines and diagnostics, an adverse impact on emergency care, etc. The medical associations have also argued that the introduction of COPRA is a step towards expensive, daunting and needless litigation. A number of other concerns have been raised by consumer forums which focus on the lack of standards for private practice, the uncertainty and risks of medicines, the effectiveness of the judiciary system, and the responsibility of proving negligence. How relevant are these concerns? Is the enactment of COPRA really appropriate to the medical sector? The paper argues that while this development is a welcome step, we need to comprehensively look into the various quality concerns. The effective implementation of COPRA presumes certain conditions, the most important being the availability of standards. Besides this, greater involvement of professional organizations is needed to ensure appropriate quality in private practice, since health and medical cases are very different from other goods and services. The paper discusses the results of a mailed survey and interview responses of 130 providers from the city of Ahmedabad, India. The questionnaire study was designed to assess the opinion of providers on various implications of the COPRA. We also analyze the data on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. Four selected cases filed with the National Commission on Consumers Redressal are discussed in detail to illustrate various issues affecting the implementation of this Act. (+info)
(4/402) Private health care provision in developing countries: a preliminary analysis of levels and composition.
While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes. (+info)
(5/402) The quality of private and public primary health care management of children with diarrhoea and acute respiratory infections in Tlaxcala, Mexico.
In Tlaxcala, Mexico, 80% of the children who died from diarrhoea or acute respiratory infections (ARI) in 1992-1993 received medical care; in more than 70% of cases it was provided by a private general practitioner (GP). The present study evaluated the quality of case management by private and public GPs to children under five years of age with diarrhoea and ARI. During the clinical observation, the treatment and counselling given to the mother were assessed with the WHO guidelines as reference standard. A total of 41 private and 40 public GPs were evaluated for the management of diarrhoea, and 59 private and 40 public GPs for the management of ARI. For diarrhoea, half of the private GPs gave inadequate rehydration therapy, 63% gave incorrect advice on diet, 66% and 49% made an incorrect correct decision in the prescription of antimicrobial and symptomatic drugs, respectively. Public GPs generally performed better in diarrhoea management: 7% gave inadequate rehydration therapy, 13% gave wrong advice on diet, 3% made a wrong decision in the prescription of symptomatic drugs and 28% gave a wrong decision in antimicrobial prescription. In the management of ARI, 66% and 58% of private GPs made a wrong decision in the prescription of antimicrobial and symptomatic drugs, respectively, compared to 30% and 20% of public GPs, respectively. Counselling to the mother given by both private and public GPs was considered inadequate in most cases of diarrhoea and ARI. These results clearly show that private doctors, as important providers of medical care, need to be included in the strategies to improve the quality of care of children with diarrhoea and ARI. Future research needs to address the determinants of the clinical practice of private doctors in countries like Mexico. (+info)
(6/402) How and why public sector doctors engage in private practice in Portuguese-speaking African countries.
OBJECTIVE: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN: Cross-sectional qualitative survey. SUBJECTS: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tome and Principe answered a self-administered questionnaire. RESULTS: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life. (+info)
(7/402) Private patients in NHS hospitals: comparison of two sources of information.
BACKGROUND: The use of National Health Service (NHS) hospitals to treat private patients is debatable on the grounds of equity of access. Hospital Episodes Statistics (HES) annual reports are the only routine source of information on the scale of this activity. The accuracy of the information is doubted. This enquiry tested the completeness of HES data against information obtained directly from private patient unit managers. METHOD: Managers of the 71 pay bed units in NHS hospitals in England were asked to supply from local registers and accounts the numbers of in-patients and day cases admitted in 1995-1996. Their reports were matched with the numbers of first consultant episodes for private in-patients and day cases shown for those hospitals in the HES data file for that year. RESULTS: Of the 71 units 62 responded; 53 of these gave usable data. The 53 included, and 18 excluded from the comparison, matched on median and range of bed numbers. Managers identified 16 per cent more total admissions than did HES, 62,572 against 54,131; 13 per cent more in-patient admissions, 39,776 against 35,319; and 21 per cent more day cases, 22,796 against 18,812. More total admissions were reported by managers of 38 pay bed units than were recorded in HES, fewer by 12, and equal numbers by three. Similar sized discrepancies were noted for in-patient admissions and day cases. Reasons for the under-reporting of private patients in HES included the use of separate patient administration systems for private patients with a failure to feed data to HES, and the omission of some provider units altogether by a minority of trusts from the returns made to the Department of Health. CONCLUSION: Overall, HES underestimates the amount of private patient activity reported directly by NHS hospitals. No method of validating private patient data is currently available. An amendment to an existing statistical return would provide a check on numbers. Central guidance on the inclusion of private patient activity in data transmitted by providers to the HES processing agency should be reinforced. (+info)
(8/402) Effectiveness of a prevention program for diabetic ketoacidosis in children. An 8-year study in schools and private practices.
OBJECTIVE: To shorten the period of carbohydrate intolerance preceding the diagnosis of IDDM in children. RESEARCH DESIGN AND METHODS: The incidence of diabetic ketoacidosis (DKA) was studied in newly diagnosed diabetic children aged 6-14 years, in the area of Parma, Italy, 8 years after an information program on DKA was introduced to teachers, students, parents, and pediatricians. Information was provided by displaying a poster with a few practical messages in 177 primary and secondary public schools. The pediatricians working in the same area were given equipment for the measurement of both glycosuria and blood glucose levels, as well as cards listing guidelines for the early diagnosis of diabetes, to be given to patients. A toll-free number was also provided. Clinical and laboratory features of 24 young diabetic patients diagnosed in the Parma area (group 1) were compared with those of 30 patients coming from two nearby areas in which no campaign for the prevention of DKA had been carried out (group 2). RESULTS: From 1 January 1991 to 31 December 1997, DKA was diagnosed in 3 children from group 1 (12.5%) and in 25 children from group 2 (83.0%) (chi 2 = 26.8; P = 0.0001). The three cases of DKA in group 1 were observed in 1991 (n = 1) and in 1992 (n = 2). No patients from the Parma area who had DKA were admitted to our unit after 1992. The duration of symptoms before diagnosis was 5.0 +/- 6.0 and 28.0 +/- 10.0 days (P < 0.0001), in groups 1 and 2, respectively, Metabolic derangements were less severe in patients of group 1 than in those of group 2. Hospitalization for the treatment of overt diabetes and for the teaching of self-management of the disease lasted 5.4 +/- 1.2 days in group 1 and 13.3 +/- 2.4 days in group 2 (P = 0.002). The total cost of the 8-year campaign was $23,470. CONCLUSIONS: The prevention program for DKA in diabetic children aged 6-14 years, carried out in the Parma area during the last 8 years, was successful. Thanks to this program, cumulative frequency of DKA in new-onset IDDM decreased from 78% during 1987-1991 to 12.5% during 1991-1997. None of the newly diagnosed diabetic children aged 6-14 years and from the Parma area were ever admitted to the hospital for DKA after 1992. (+info)