User fees and patient behaviour: evidence from Niamey National Hospital.
(17/7828)
Evidence is presented on the effects of price changes on the delay before seeking care and on referral status in a sample of hospital patients in Niger. Price changes are measured as differences across patients at one hospital in whether or not they pay for care, rather than as differences in prices across several hospitals. User fees are charged, but the fee system allows exemptions for some payor categories such as government employees, students, and indigent patients. Evidence is also presented on the effect of income on the delay before seeking care and referral status. The analysis demonstrates a technical point on whether household consumption or current income is a more appropriate measure of income. The analysis shows that user fees affect patient behaviour, but the effects are not the same for outpatients and inpatients. Outpatients who pay for care wait longer before seeking care, but inpatients do not. Inpatients who pay for care are more likely to be referred, but outpatients are not. Patients with more income wait less time to seek care and are less likely to be referred than other patients. Further, household consumption explains patient behaviour better than current income. (+info)
Predictors for waiting time for coronary angioplasty in a high risk population.
(18/7828)
Objective--To describe the clinical and non-clinical factors which influence the waiting time from initial angiography to angioplasty. Design--Follow up of a random sample of 106 patients undergoing their first coronary angiography for whom a decision to revascularise by percutaneous transluminal angioplasty was made in 1991. The period between the date of angiography and the date of angioplasty and various clinical characteristics of patients were retrieved from medical notes in mid 1993. Patients were sampled from those investigated in the two Northern Ireland catheterisation laboratories in Belfast, which provide services for the whole of the province (population 1.5 million). Main measures--The dependent variable was the period between initial angiography and angioplasty, and the independent variables included age, sex, distance from cardiac catheterisation centre, referral source, characteristics of the clinical history, severity of angina, and anatomical extent of disease. Cox's proportional hazards analysis was used to derive a relative hazard, expressing the relative chances of revascularisation occurring at any time during follow up. Results--Of the 106 patients studied, 93 had had percutaneous transluminal angioplasty at follow up. The most important predictors of waiting time were the presence of severe angina (relative hazards 3.1(95 % confidence interval (95% CI) 1.4-6.8) and 2.7(1.2-6.2) for Canadian Cardiovascular grades III and IV v angina grade I angina), a recent history of myocardial infarction (relative hazard, 2.5(1.3-4.8), and whether or not the patient was economically active (relative hazard 0.6(0.4-1.0) for economically inactive v active patients). Although there was also an association with the relative deprivation of the area of residence of the patient it had no clear linear trend. Conclusions--Although waiting time for percutaneous transluminal angioplasty was predictably related to the patient's clinical presentation, demographic factors may also be important in determining access to intervention. These factors clearly merit further study; ultimately, the evaluation of equity in a waiting time distribution may more properly be a societal rather than a clinical judgment. (+info)
Policy priorities in diabetes care: a Delphi study.
(19/7828)
OBJECTIVES: To produce policy priorities for improving care of diabetes based on the findings of original research into patient and professional opinions of diabetes care in South Tyneside. To judge the feasibility of implementing these priorities as policy. DESIGN: A two round Delphi survey with a panel of 28 inverted question markexperts. inverted question mark In the first round each respondent produced a list of recommendations based on the findings of a report of patients' and professionals' opinions of diabetes care. 20 respondents produced a total of 180 recommendations, reviewed by a monitoring panel to produce a summary list of 28 recommendations. In the second round respondents rated each recommendation on two 5 point Likert scales. SETTING: Mainly Tyneside but also other parts of England. SUBJECTS: 28 healthcare professionals, including patients and patients' representatives. MAIN MEASURES: Voting by experts on how important each recommendation was to improving diabetes care service, and how likely the recommendation was to be implemented in the next five years. RESULTS: There was a high degree of consensus among respondents about recommendations considered important and likely to be implemented--namely, those concerned with improving communications between doctors in hospital and in general practice, and improving communications with patients. Respondents were more pessimistic about the prospects of implementing the recommendations than about their importance. Respondents thought that standards were important for improving care, and half would stop payments to general practice diabetic clinics that did not keep to district standards for diabetes care. For two recommendations a mismatch occurred between the importance of the recommendations and likelihood of implementation. This may reflect the practical problems of implementing recommendations. 18 of the 22 respondents thought that the study was useful in generating recommendations. CONCLUSIONS: The Delphi technique is a useful method for determining priorities for diabetes care and in assessing the feasibility of implementing recommendations. (+info)
Indicators of the quality of general practice care of patients with chronic illness: a step towards the real involvement of patients in the assessment of the quality of care.
(20/7828)
OBJECTIVE: To develop a list of indicators of the general practice care of people with chronic illnesses considered important by both patients and practitioners and to identify the indicators that are considered relevant for patient assessment of health care quality. DESIGN: Qualitative study with focus group interviews and a written consensus procedure. SETTING: General practice in the Netherlands in 1993. SUBJECTS: 34 patients with chronic illness, mostly members of patient organisations, and 19 general practitioners with expertise in either chronic disease management or experience with patient surveys. MAIN MEASURES: Aspects of general practice care considered important for the delivery of good quality care that emerged from focus group interviews; the relevance of evaluations of 41 aspects of care for patients explored through the written consensus procedure. Those aspects of general practice care agreed to be both important and relevant by patients and general practitioners were considered to be suitable indicators for patient assessment of the quality of care. RESULTS: Patients and general practitioners differed to some extent in their assessment of the aspects of care that they considered important for quality. They agreed that most indicators of care that related to the inverted question markdoctor-patient relation inverted question mark and to inverted question markinformation and support inverted question mark were relevant and therefore suitable as indicators for patient assessment of health care quality. There was less agreement about the relevance of indicators of inverted question markmedical and technical care, inverted question mark inverted question markavailability and accessibility, inverted question mark and inverted question markorganisation of services. inverted question mark CONCLUSIONS: Several indicators of the quality of general practice care of patients with chronic illness were thought to be suitable for the patient assessment of healthcare quality, but other indicators were not, mainly because of reservations by general practitioners. IMPLICATIONS: Qualitative methods can contribute to the selection of indicators for assessment of the quality of health care in areas where scientific evidence is limited or where patients' and providers' preferences are particularly important. (+info)
Ethnicity, nationality and health care accessibility in Kuwait: a study of hospital emergency room users.
(21/7828)
In mid-1994, non-Kuwaiti expatriates constituted 61.7% of the total population of Kuwait (1.75 million). Despite this numerical majority, non-Kuwaitis exist as a social minority. Non-Kuwaitis may be grouped into three broad categories along ethnic/nationality lines into Bidoon (without nationality), Arabs, and Asians. The objective of this paper was to compare the relative accessibility of the various groups to health care services in Kuwait. The study is based on data collected as part of a survey of 2184 Emergency Room (ER) users in January-February 1993. All patients attending the hospital ERs between 7:30 am and 9:00 pm were interviewed about their reasons for coming to the ER instead of going to the primary health care (PHC) centres, as required. The major reason given was low accessibility of the PHCs. Compared to Kuwaiti nationals, 92% of whom were registered at the PHC centres, only 62% of the Arabs and 39% of the Asians were registered. Multiple logistic regression of the factors in registration indicated that nationality was the most important reason for lack of registration, with Asians only about one-quarter as likely to be registered as Kuwaitis. Also, people who had been in Kuwait for shorter durations (< 5 years) were less likely to be registered than the Kuwaiti nationals or expatriates who had been here for 10 years or longer. In the absence of registration at the PHC centre, the civil identification card (ID) may be used as a valid means to enter the health system. Among the Arabs and Asians, 22% and 29% did not have a civil ID card. Thus, for many expatriates, the hospital ER, which does not provide the necessary follow-up care is often the only source of health care available. (+info)
Developing a plan for primary health care facilities in Soweto, South Africa. Part II: Applying locational criteria.
(22/7828)
This article is the second of a two-part series describing the development of a ten-year plan for primary health care facility development in Soweto. The first article concentrated on the political problems and general methodological approach of the project. This second article describes how the technical problem of planning in the context of scanty information was overcome. The reasoning behind the various assumptions and criteria which were used to assist the planning of the location of facilities is explained, as well as the process by which they were applied. The merits and limitations of this planning approach are discussed, and it is suggested that the approach may be useful to other facility planners, particularly in the developing world. (+info)
The privatization of health care in three Latin American social security systems.
(23/7828)
Most Latin American social security institutes are direct providers of medical care services to their beneficiaries. As many of the institutes have developed serious financial problems over the course of the last decade and a half, they have come under increasing attack for (a) exacerbating inequalities in access to and use of health care, (b) further heightening the geographic overconcentration of services, (c) focusing a disproportionate amount of resources on high technology, curative care to the near total exclusion of primary health care, and (d) being administratively top heavy and, more generally, inefficient. In the past few years, many Latin American countries have begun searching for methods to ameliorate these problems. This paper analyzes three recent efforts, all of which involve some degree of privatization: (1) El Salvador's partial privatization of specialty physician outpatient consultations, (2) Peru's minor surgery and its decentralized ambulatory care programme, and (3) Nicaragua's "administrative services only' approach wherein social security beneficiaries choose to join a certified public or private provider organization for one year, and, on behalf of the individual, social security pays the organization a fixed, annual, per capita fee to provide all health care for the enrollee. The paper also identifies political and technical considerations, as well as health care market characteristics that have shaped these efforts and that condition their likelihood of success, including: the size, composition, level of capacity utilization, degree of organization and geographic distribution of private sector resources; relative prices in the private vis-a-vis the public sector; and the size and nature of the private health insurance market. Other Latin American countries would do well to examine these factors and characteristics before embarking on efforts to reform their own social security health care delivery systems. (+info)
Operational factors affecting maternal mortality in Tanzania.
(24/7828)
Identification of the main operational factors in cases of maternal death within and outside the health care system is necessary for safe motherhood programmes. In this study, a follow-up was done of all 117 cases of maternal deaths in Ilala district, Dar es Salaam, 1991-1993, at all levels of care. In all, 79% received some medical care whereas 11% arrived too late for treatment. For each case the major operational factors and all health care interventions were defined through interviews with family members and health care staff and from hospital records, and the avoidability of each case was determined. In the health institutions where the women had consulted, the available resources were assessed. It was found that in most cases the husband (29%) or the mother (31%) of the woman decided on her care in cases of complications, and together with the lack of transport, this often caused delay at home. Also, delay in transfer from the district hospital was common. Cases of abortion complications were often not managed on time because of the delay in reporting to hospital or misleading information. Suboptimal care was identified in 77% of the cases reaching health care. Inadequate treatment was identified by the district health staff in 61% and by the referral centres in 12% of their cases. Wrong decision at the district level and lack of equipment at the referral centre were the main reasons for inadequate care. It is concluded that although community education on danger signs in pregnancy and labour is important, provision of the core resources and supplies for emergency obstetric interventions, as well as clear protocols for management and referral, are absolutely necessary for improvement of maternal survival. (+info)