Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system.
(73/22207)
BACKGROUND: Recent studies from the United States have shown that institutions with higher numbers of pancreatic resection procedures for neoplasm have lower mortality rates associated with this procedure. However, minimal work has been done to assess whether the results of similar volume-outcome studies within a publicly financed health care system would differ from those obtained in a mixed public-private health care system. METHODS: A population-based retrospective analysis was used to examine pancreatic resection for neoplasm in Ontario for the period 1988/89 to 1994/95. Outcomes examined included in-hospital case fatality rate and mean length of stay in hospital. For each hospital, total procedure volume for the study period was defined as low (fewer than 22), medium (22-42) or high (more than 42). Regression models were used to measure volume-outcome relations. RESULTS: The likelihood of postoperative death was higher in low-volume and medium-volume centres than in high-volume centres (odds ratio 5.1 and 4.5 respectively; p < 0.01 for both). Mean length of stay was greater in low- and medium-volume centres than in high-volume centres (by 7.7 and 9.2 days respectively, p < 0.01 for both). INTERPRETATION: This study adds to growing evidence that, for pancreatic resection for neoplasm, patients may have better outcomes if they are treated in high-volume hospitals rather than low-volume hospitals. (+info)
Perceived visual ability for independent mobility in persons with retinitis pigmentosa.
(74/22207)
PURPOSE: To determine the distribution of perceived ability for independent mobility in people who are at various stages of retinitis pigmentosa (RP). METHODS: A questionnaire was developed to ask subjects to rate how difficult they found each of 35 mobility situations if they had no assistance. The scale was 1 (no difficulty) to 5 (extreme difficulty). In each of 127 subjects, the Rasch analysis, a latent trait analysis, was used to convert the ordinal difficulty ratings into interval measures of perceived visual ability for independent mobility. RESULTS: Content validity of the questionnaire was shown by good separation indexes (4.55 and 8.0) and high reliability scores (0.96 and 0.98) for the person and the item parameters. Construct validity was shown with model fit statistics. Criterion validity of the questionnaire was shown by good discrimination among mobility-related behavior such as "limit independent travel," "always ask for accompaniment," "use a mobility aid," and "have a fear of falling." The mobility situation shown to require the least visual ability was "moving about in the home"; the situation requiring the most was "walking at night." Bivariate regression analysis determined that for every decade of disease progression, perceived visual ability for mobility decreased by approximately 0.5 logit, which was slightly less than 10% of the total range in the study sample. A linear combination of the visual function measures, log minimum angle of resolution, log contrast sensitivity, and log retinal area accounted for 57% of the variability in the person measure. CONCLUSIONS: The patient-based assessment, developed to determine difficulty across a range of mobility situations, is a valid way to measure perceived ability for independent mobility. This latent trait varies systematically with the progression of RP and with visual function measures. (+info)
Is health insurance in Greece in need of reform?
(75/22207)
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)
Selection for oesophagectomy and postoperative outcome in a defined population.
(76/22207)
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)
Towards measurement of outcome for patients with varicose veins.
(77/22207)
OBJECTIVE: To develop a valid and reliable outcome measure for patients with varicose veins. DESIGN: Postal questionnaire survey of patients with varicose veins. SETTING: Surgical outpatient departments and training general practices in Grampian region. SUBJECTS: 373 patients, 287 of whom had just been referred to hospital for their varicose veins and 86 who had just consulted a general practitioner for this condition and, for comparison, a random sample of 900 members of the general population. MAIN MEASURES: Content validity, internal consistency, and criterion validity. RESULTS: 281(76%) patients (mean age 45.8; 76% female) and 542(60%) of the general population (mean age 47.9; 54% female) responded. The questionnaire had good internal consistency as measured by item-total correlations. Factor analysis identified four important health factors: pain and dysfunction, cosmetic appearance, extent of varicosity and complications. The validity of the questionnaire was demonstrated by a high correlation with the SF-36 health profile, which is a general measure of patients' health. The perceived health of patients with varicose veins, as measured by the SF-36, was significantly lower than that of the sample of the general population adjusted for age and a lower proportion of women. CONCLUSION: A clinically derived questionnaire can provide a valid and reliable tool to assess the perceived health of patients with varicose veins. IMPLICATIONS: The questionnaire may be used to justify surgical treatment of varicose veins. (+info)
Factors influencing default at a hospital colposcopy clinic.
(78/22207)
OBJECTIVE: To identify factors reducing compliance at diagnosis, treatment, and review stages among women referred with abnormal cervical smears to a hospital colposcopy clinic. DESIGN: Retrospective analysis of sociodemographic data from hospital notes of the attenders and defaulters during one year (1989-90) and prospective collection of information by structured interviews of a sample of defaulters and attenders during five months (May-September 1990). SETTING: One hospital colposcopy clinic. PATIENTS: 238 women defaulting on two consecutive occasions and 188 attending regularly (retrospective analysis) and a subset of 40 defaulters and 24 attenders (interview sample). MAIN MEASURES: Sociodemographic data and interview responses about attitudes, behaviour, choice, accessibility cultural understanding, communications, and emotional response. RESULTS: 22 (12%) women defaulted at diagnosis, 24(13%) at treatment, 39(21%) at the first check up after treatment, and 84(45%) at the review stage; 19(10%) defaulted from the first check up after diagnostic examination revealed no need for treatment. Age and social class differed between the two groups. 181(76%) defaulters were under 30 compared with 91(48%) attenders; 14(6%) compared with 41(23%) were over 40(p < 0.001). The proportion of women in social classes 4 and 5 was 33%(20/60) for defaulters and 21%(25/120) for attenders (p < 0.05) and unemployed was 66%(158/238) and 36%(68/188) respectively. 63(28%) defaulters were pregnant compared with 11(6%) attenders (p < 0.001). More defaulters came from gynaecology or antenatal clinics. Most defaulters (93%) had child care responsibilities and they knew and understood less about colposcopy. Their explicit reasons for defaulting included child care commitments and fear and their implicit reasons lack of understanding, inaccessibility of information, and staff attitudes. CONCLUSIONS: Compliance may be improved by promoting women's understanding of treatment and encouraging health professionals to develop a service more sensitive to the various needs of women in different socioeconomic groups. (+info)
The impact of alternative cost recovery schemes on access and equity in Niger.
(79/22207)
The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for-service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods. (+info)
R(80/22207)
esearch note: does cost recovery for curative care affect preventive care utilization?
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