Ethnicity, nationality and health care accessibility in Kuwait: a study of hospital emergency room users.
(73/10069)
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)
Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria.
(74/10069)
This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed. (+info)
Willingness to pay for district hospital services in rural Tanzania.
(75/10069)
This paper describes a study undertaken to investigate the willingness of patients and households to pay for rural district hospital services in north-western Tanzania. The surveys undertaken included interviews with 500 outpatients and 293 inpatients at three district level hospitals, interviews with 1500 households and discussions with 22 focus groups within the catchment areas of the primary health care programmes of these hospitals. Information was collected on willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The willingness to pay for district hospital services was large. Furthermore, most respondents favoured a local insurance system above user fee systems, a finding which applied at all places and in all the surveys. More female respondents were in favour of a local insurance scheme. The conditions needed for the introduction of a local insurance system are discussed. (+info)
Essential dataset for ambulatory ear, nose, and throat care in general practice: an aid for quality assessment.
(76/10069)
OBJECTIVE: To describe the documentation of care for the usual range of ear, nose, and throat (ENT) problems seen in primary care as a basis for developing a computerised information system to aid quality assessment. DESIGN: Descriptive study of the pattern of ENT problems and diagnoses and treatment as recorded in individual case notes. SETTING: The primary health care centre in Mjolby, Sweden. PATIENTS: Consultations for ENT problems from a 10% sample randomly selected from all consultations (n = 22,600) in one year. From this sample 375 consultations for ENT problems (16% of all consultations) by 272 patients were identified. MAIN MEASURES: The detailed documentation of each consultation was retrieved from the individual records and compared with the data required for a computer based information system designed to help in quality management. RESULTS: Although the overall picture gained from the data retrieved from the notes suggested that ENT care was probably adequate, the recorded details were limited. The written case notes were insufficient when compared with the details required for a computerised system based on an essential dataset designed to allow assessment of diagnostic accuracy and appropriateness of treatment of ENT problems in primary care. CONCLUSION: There is a gap between the amount and the type of information needed for accurate and useful quality assessment and that which is normally included in case notes. More detailed information is needed if general practitioners' notes are to be used for regular quality assessment of ENT problems but that would mean more time spent on keeping notes. This would be difficult to justify. IMPLICATIONS: The routine information systems used at this primary healthcare centre did not produce sufficient documentation for quality assessment of ENT care. This dilemma might be resolved by specially designed desktop computer software accessed through an essential dataset. (+info)
What quality measurements miss.
(77/10069)
Measurable indices of health care quality are all the rage these days. But physicians know that not everything in health care can be quantified. If reportable numbers become our principal focus, what is in danger of falling through the cracks? (+info)
Health outcomes and managed care: discussing the hidden issues.
(78/10069)
Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider-patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty. (+info)
Effects of a computerised protocol management system on ordering of clinical tests.
(79/10069)
OBJECTIVE: To assess the effects of a computerised protocol management system on the number, cost, and appropriateness of laboratory investigations requested. DESIGN: A before and after intervention. SETTING: A supraregional liver unit in a teaching hospital. PATIENTS: 1487 consecutive patients admitted during 1990 and 1991 (one year before and one year after introduction of the system). INTERVENTION: Introduction of a computerised protocol management system on 1 January 1991. MAIN MEASURES: The number and cost of clinical chemistry tests requested per patient day. RESULTS: The total number of clinical chemistry tests requested per patient day by the unit declined 17% (p < 0.001, Student's t test) and of out of hours tests requested per patient day from 0.31 to 0.16, 48% (p < 0.001; Mann-Whitney U test), resulting in a 28% reduction (p < 0.001) in direct laboratory expenditure per patient-day. Overall, the number of tests per admission decreased by 24% (p < 0.001; Mann-Whitney U test). CONCLUSION: Use of the computerised protocol management system resulted in closer compliance with the protocols and a significant reduction in the overall level of requesting. IMPLICATIONS: Although similar systems need to be tested in other clinical settings, computerised protocol management systems may be important in providing appropriate and cost effective health care. (+info)
Prospective audit comparing ambulatory day surgery with inpatient surgery for treating cataracts.
(80/10069)
OBJECTIVES: To compare the cost effectiveness and safety of inpatient cataract surgery (with one night in hospital postoperatively) with ambulatory day case surgery under local anaesthesia. DESIGN: Prospective study of patients receiving inpatient (group 1) or day case (group 2) surgery. SETTING: One ophthalmic surgical firm. PATIENTS: 100 patients in each group, excluding those with coexisting ocular conditions, contraindications to local or request for general anaesthesia, ill health, or lack of agreed minimum social care; four patients died during follow up. INTERVENTIONS: Envelope method and implantation of the posterior chamber lens into the capsular sac in both groups. MAIN MEASURES: Perioperative complications, operating and turnover times, visual outcome at three to six days and 10 weeks to six months after operation, patient satisfaction (according to self administered questionnaire) at three to six days, and total costs (1989 salaries) for both groups. RESULTS: Patients in both groups did not differ significantly in age or sex, perioperative complications, visual outcome (6/9 or better in 78 patients in group 1 and 75 in group 2 at one month after operation and 6/12 or better in 92/98 in group 1, 90/98 in group 2 at final follow up), or patient satisfaction. The mean total cost per patient for group 1 patients was 365.99 pounds and for group 2, 221.62 pounds. CONCLUSIONS: Day case surgery for cataract is safe and more cost effective. IMPLICATIONS: Day case surgery should be recommended to increase availability of cataract surgery and thereby improve quality of life for more patients. (+info)