National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society.
(17/5276)
OBJECTIVE: To ascertain the standard of care for hospital management of acute severe asthma in adults. DESIGN: Questionnaire based retrospective multicentre survey of case records. SETTING: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland. PATIENTS: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management. MAIN MEASURES: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians. RESULTS: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan. CONCLUSIONS: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians. (+info)
Mortality league tables: do they inform or mislead?
(18/5276)
OBJECTIVE: To examine certain methodological issues related to the publication of mortality league tables, with particular reference to severity adjustment and sample size. DESIGN: Retrospective analysis of inpatient hospital records. SETTING: 22 hospitals in North West Thames health region for the fiscal year 1992-3. SUBJECTS: All admissions with a principal diagnosis of aortic aneurysm, carcinoma of the colon, cervical cancer, cholecystectomy, fractured neck of femur, head injury, ischaemic heart disease, and peptic ulcer. MAIN MEASURES: In hospital mortality rates adjusted by disease severity and calculated on the basis of both admissions and episodes. RESULTS: The numbers of deaths from specific conditions were often small and the corresponding confidence intervals wide. Rankings of hospitals by death rate are sensitive to adjustment for severity of disease. There are some differences that cannot be explained using routine data. CONCLUSIONS: Comparison of crude death rates may be misleading. Some adjustment for differences in severity is possible, but current systems are unsatisfactory. Differences in death rates should be studied, but because of the scope for manipulating data, this should be undertaken in a collaborative rather than a confrontational way. Any decision to publish league tables of death rates will be on political rather than scientific grounds. (+info)
User charges in government health facilities in Kenya: effect on attendance and revenue.
(19/5276)
In this paper we study demand effects of user charges in a district health care system using cross-sectional data from household and facility surveys. The effects are examined in public as well as in private health facilities. We also look briefly at the impact of fees on revenue and service quality in government facilities. During the period of cost-sharing in public clinics, attendance dropped by about 50%. This drop prompted the government to suspend the fees for approximately 20 months. Over the 7 months after suspension of fees, attendance at government health centres increased by 41%. The suspension further caused a notable movement of patients from the private sector to government health facilities. The revenue generated by user fees covered 2.4% of the recurrent health budget. Some 40% of the facilities did not spend the fee revenue they collected, mainly due to cumbersome procedures of expenditure approvals. The paper concludes with lessons from Kenya's experience with user charges. (+info)
Health services research in the English-speaking Caribbean 1984-93: a quantitative review.
(20/5276)
Evaluating the effectiveness and efficiency of health services is important for all countries, especially those with limited resources. This study aimed to evaluate the volume and quality of health services research (HSR) conducted in one developing region, the English-speaking Caribbean. Data were abstracted from all 770 abstracts describing presentations at the annual scientific meetings of the Commonwealth Caribbean Medical Research Council for the decade 1984 to 1993. Of these, 341 abstracts were judged to report health services research and were from the English-speaking Caribbean. Hospital services were evaluated in 240 (70%) reports while primary health services were evaluated in only 90 (26%). Most hospital-based studies evaluated the use and outcome of medical and surgical services through the collection of case series and cohorts of cases, with a median sample size of 104 (interquartile range 38 to 320). Evaluations at primary level were more likely to evaluate need or demand for services, were more likely to report cross sectional surveys or randomized trials and included larger numbers of subjects (median 343, interquartile range 121 to 661). Patient-based measures of health status and measures of resource use were not often reported at either primary or secondary level. Estimation and hypothesis testing were infrequently employed in data analysis. A large proportion of the research presented could be classified as HSR but measures are needed to increase the motivation for research into primary care and to improve skills in HSR study design, conduct and analysis among those presently conducting research. (+info)
Overview: health financing reforms in Africa.(21/5276)
Protecting the poor under cost recovery: the role of means testing.
(22/5276)
In African health sectors, the importance of protecting the very poor has been underscored by increased reliance on user fees to help finance services. This paper presents a conceptual framework for understanding the role means testing can play in promoting equity under health care cost recovery. Means testing is placed in the broader context of targeting and contrasted with other mechanisms. Criteria for evaluating outcomes are established and used to analyze previous means testing experience in Africa. A survey of experience finds a general pattern of informal, low-accuracy, low-cost means testing in Africa. Detailed household data from a recent cost recovery experiment in Niger, West Africa, provides an unusual opportunity to observe outcomes of a characteristically informal means testing system. Findings from Niger suggest that achieving both the revenue raising and equity potential of cost recovery in sub-Saharan Africa will require finding ways to improve informal means testing processes. (+info)
Improving quality through cost recovery in Niger.
(23/5276)
New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost-effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements. (+info)
Efficiency and quality in the public and private sectors in Senegal.
(24/5276)
It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access. (+info)