Les facteurs associés à la mortalité intrapartum et néonatale très précoce au niveau de la maternité du centre hospitalier universitaire Mohammed VI,Marrakech, Maroc. Étude cas témoin

BackgroundPer-partum stillbirth continues to represent a public health burden despite the efforts of countries around the world. Prevention of this mortality can only be effective with a better knowledge of factors that are life-threatening to the fetus or newborn. This work aims to determine associated factors with intrapartum and very early neonatal mortality.MethodsA case-control study was carried out at the maternity of the university hospital in Marrakech, where 290 subjects were selected: 145 cases of intrapartum fetal death or a very early neonatal death, and 145 controls of surviving newborn weighing 2500 g or more at birth. Data were collected from obstetric, partogram and death records for the year 2016. The factors that were compared between the two groups were factors before admission to maternity, factors related to the management during labor and to the care of newborn.ResultsStatistically significant associations were found between these deaths and several factors including: multiparity versus primiparity adjusted OR = 2.27 [1.17–4.42], pregnant women referral from another health facility adjusted OR = 2.11 [1.12–3.99], care for women during the transfer adjusted OR = 0.21 [0.9–0.49] and prenatal follow-up of pregnancy adjusted OR = 0.22 [0.12–0.4]. Were also associated: fetal monitoring during labor adjusted OR = 0.22 [0.08–0.62], neonatal respiratory distress adjusted OR = 18.48 [7.60–44.98] and Apgar score (⩽ 7) adjusted OR = 6.05 [2.51–14.62].ConclusionIntrapartum and very early neonatal mortality is closely related to the newborn's condition at birth, fetal monitoring during labor, pregnancy monitoring, and the organization of the referral system.     

Risk factors for perinatal mortality in the city of Lubumbashi, Democratic Republic of Congo

BackgroundThe aim of this study is to establish factors explaining perinatal death rates in the city of Lubumbashi.MethodsWe have carried out a case controlled study in the maternity ward of Jason Sendwe hospital. Perinatal death cases have been compared to those of surviving newborn children among parturient women in the course of 2008. Sociodemographic characteristics, maternal morbidity, children's typical features, have been studied as independent variables. Their effect on perinatal mortality has been assessed using an adjusted odds ratio value at a 5% confidence interval and a logistic regression model.ResultsIn total, we considered 2279 births (mother and child pairs) for our study. Among these were 415 perinatal mortality cases and 1864 control cases. After adjustment for several parameters, household chores (AOR = 1.8; 95% IC = 1.2–2.9), multiple pregnancies (AOR = 1.9; 95% IC = 1.2–2.9), malaria (AOR = 1.4; 95% IC = 1.1–1.8), primiparity (AOR = 1.7; 95% IC = 1.3–2.4), stillbirth (AOR = 5.2; 95% IC = 2.5–11.0) and prematurity (AOR = 2.9; 95% IC = 1.5–5.5) in previous pregnancies, onset of antepartum ferver (AOR = 3.0; 95% IC = 1.2–7.3) and antepartum hemorrhage (AOR = 6.8; 95% IC = 3.1–15.0), lack of fetal motions near delivering time, dystocias (AOR = 2.0; 95% IC = 1.3–3.0), low birthweight (AOR = 15.7; 95% IC = 11.2–22.0), very low birthweight (AOR = 49.0; 95% IC = 28.6–85.1) and foetal macrosomia (AOR = 3.5; 95% IC = 1.8–7.0) were the main factors explaining perinatal mortality.ConclusionPerinatal mortality in Lubumbashi remains associated with several avoidable factors. Basic and emergency obstetrical-neonatal care (B-EMONC) should be improved. Significant efforts should be made in this direction. Perinatal audits should be established for a good heath care quality follow-up. Obstetrical care should be offered as a continuum in order to facilitate communication between the different caregivers.     

Utilisation des données recueillies en routine pour évaluer l’activité des maternités au Mali et au Sénégal (essai QUARITE)

BackgroundIn sub-Saharan Africa, problems of access to relevant and high-quality facility-based statistics hinder the assessment of safe motherhood programs. The objective of this study was to assess the quality of data collected in referral hospitals in Mali and Senegal after the routine information system (RIS) was strengthened.MethodsThis was a multicenter observational study conducted during the pre-intervention period of a randomized controlled trial (trial QUARITE). The RIS was strengthened based on technical, organizational and behavioral factors. We included all women who gave birth in the 46 referral hospitals from October 1, 2007 to October 30, 2008. The completeness, completion and accuracy rates were monitored every 3 months in each hospital. The cost of investment needed to strengthen the existing RIS was also determined.ResultsThe mean completeness rate ranged from 94 to 97% depending on the study period. The completion and accuracy rates increased during the study period from 72% and 79% to 87% and 93%, respectively (significant differences). The average investment per hospital was less than 1% of state subsidies for public hospitals.ConclusionStrengthening the existing information system has set up an economically and technologically appropriate system for monitoring maternal and perinatal health in Senegal and Mali. We encourage policy makers and researchers from countries with limited resources to invest in RIS to improve and monitor the performance of health systems.     

Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort

BackgroundThe objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization.MethodsA prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period.ResultsCrude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR = 1.83; 95% CI = 1.27–2.62) or a higher number of children (HR = 0.86; 95% CI = 0.78–0.96), balance problems (HR = 1.72; 95% CI = 1.19–2.47), malnutrition or risk thereof (HR = 1.93; 95% CI = 1.24–3.01), and dementia syndrome (HR = 1.88; 95% CI = 1.32–2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR = 1.92; 95% CI = 1.17–3.16), delirium (HR = 1.80; 95% CI = 1.24–2.62), and a high level of comorbidity (HR = 1.62; 95% CI = 1.09–2.40). Institutionalization (HR = 1.92; 95% CI = 1.37–2.71) and unplanned readmission (HR = 4.47; 95% CI = 3.16–2.71) within the follow-up period were also found as independent predictors.ConclusionThe main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects’ prognosis favorably.     

Mainly the younger hypothyroid patients are referred to hospital--evidence for referral bias

ObjectiveStudies of hypothyroidism are often based on patients referred to hospital. It is unknown, to what extent such studies are referral biased. Thus, the aim of the present study was to evaluate the magnitude of selection bias in a study of patients newly diagnosed with hypothyroidism.Study Design and SettingA computer-based system linked to laboratory databases identified patients with incident overt hypothyroidism (n = 346) from 1997 to 2000 in Aalborg, Denmark. An electronic patient administrative system identified patients referred to Department of Endocrinology, Aalborg Hospital. Among patient characteristics recorded at the time of diagnosis—age, gender, nosological subgroup of hypothyroidism, thyroid stimulating hormone (TSH), total thyroxine (T4), total triiodothyronine (T3), thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), and calendar year—we searched for predictors of referral state.ResultsOf all hypothyroid patients, 86 (25%) were referred to our endocrine unit. The referred patients were younger (50.4 vs. 66.0 years, P < 0.001), had higher serum TSH (53.6 vs. 32.6 mU/L, P = 0.002) and lower serum total T4 (37.0 vs. 44.0 nmol/L, P = 0.03) compared with nonreferred patients. In a multivariate model, only less age (P < 0.001) and serum total T4 (P = 0.03) were statistically associated with referral state.ConclusionHypothyroid patients referred to a specialized hospital unit were younger and marginally more hypothyroid than nonreferred patients. Thus, referral bias should always be considered in hospital-based studies of hypothyroid patients.     

Brief education to promote maternal influenza vaccine uptake: A randomized controlled trial

BackgroundAlthough pregnant women are the highest priority group for seasonal influenza vaccination, maternal influenza vaccination rates remain suboptimal. The purpose of this study was to evaluate the effect of a brief education intervention on maternal influenza vaccine uptake.MethodsDuring the 2013–14 and 2014–15 influenza seasons, we recruited 321 pregnant women from the antenatal clinics of 4 out of 8 public hospitals in Hong Kong with obstetric services. Hospitals were geographically dispersed and provided services to pregnant women with variable socioeconomic backgrounds. Participants were randomized to receive either standard antenatal care or brief one-to-one education. Participants received telephone follow-up at 2 weeks postpartum. The primary study outcome was self-reported receipt of influenza vaccination during pregnancy. The secondary outcomes were the proportion of participants who initiated discussion about influenza vaccination with a health care professional and the proportion of participants who attempted to get vaccinated.ResultsCompared with participants who received standard care, the vaccination rate was higher among participants who received brief education (21.1% vs. 10%; p = 0.006). More participants in the education group initiated discussion about influenza vaccination with their HCP (19.9% vs. 13.1%; p = 0.10), but the difference was not statistically significant. Of participants who did not receive the influenza vaccine (n = 271), 45 attempted to get vaccinated. A significantly higher proportion of participants who attempted to get vaccinated were in the intervention group (82.2% vs. 17.8%; p < 0.001). If participants who had attempted vaccination had received the vaccine, vaccination rates would have been substantially higher (44.1% vs. 15%; p < 0.001). Twenty-six participants were advised against influenza vaccination by a healthcare professional, including general practitioners, obstetricians, and nurses.ConclusionAlthough brief education was effective in improving vaccination uptake among pregnant women, overall vaccination rates remain suboptimal. Multicomponent approaches, including positive vaccination recommendations by healthcare professionals, are needed to promote maternal influenza vaccination.Clinical Trial Registration: www.clinicaltrials.gov (NCT01772901).     

Factors determining the place of delivery in women who attended at least one antenatal consultation in a health facility (Senegal)

BackgroudHome birth remains a major cause of maternal and neonatal deaths in Senegal. The objective of this study was to identify the determinants of home birth in women who attended at least one antenatal consultation during their last pregnancy.MethodThe study was cross-sectional and analytical. It covered a sample of 380 women selected at random among those who have given birth in the last 12 months in the health district Gossas. Data were collected at home using a questionnaire during an interview after informed consent. Multiple logistic regression was used to explore the determinants of childbirth at home using the Andersen model.ResultsThe mean age was 26.2 ± 6.1 years. Women were married (97.3%), illiterate (81.8%) and lived in rural areas (78.4%). Available means of transportation at home were car (7.6%), cart (62.9%) or none 29.5%. In addition, 52.2% of the women lived more than 5 km from a health facility. For 59.0% of the women, the prenatal exam was considered satisfactory. The prevalence of home birth was 24%. Factors related to birth at home are polygamous marriage (OR = 2.04 [1.13–3.70]), lack of transportation (OR = 2.11 [1.13–5.01]) and residence more than 5 km from a health facility (OR = 2.68 [1.56–4.16]). Late (3.90 [2.30–6.65]) or low quality (4.27 [2.25–8.10]) prenatal exams were also risk factors.ConclusionHome birth is linked to access to health facilities but also to the prenatal consultation. Particular emphasis should be placed on training health care providers to improve the quality of the patients in the structures.     

Association of Physician Certification Policy and Quality of Care: Evidence of percutaneous coronary intervention certification program in Taiwan

ObjectivesThe aim of this study was to compare procedural, short-term and two-year outcomes of percutaneous coronary intervention (PCI) between board-certified and non-board certified interventional cardiologists in Taiwan.BackgroundMost studies of associations between quality and certification have analyzed populations in the Western developed countries.MethodsThis retrospective population-based study analyzed 2057 patients who had received PCI in 11 hospitals in 2007. The outcome measures were procedural, 30-day, and 2-year adverse events.ResultsSixty certified physicians performed 1771 PCI procedures whereas 84 non-certified physicians performed 286 procedures. Patients treated by non-certified physicians had significantly higher rates of in-hospital mortality (6.99% vs. 2.82%, respectively; p ≤ 0.001) and same-stay CABG (1.40% vs. 0.06%, respectively; p ≤ 0.001). The results of multilevel logistic regression and Cox multivariate regression indicated that patients treated by non-certified physicians also had higher probabilities of in-hospital death (OR = 2.92, 95% CI: 1.20–7.08) and two-year death (hazard ratio, 1.63; 95% confidence interval, 1.18–2.24).ConclusionsThis is the first study in Asia in investigating the association between board certification policy and surgical outcomes, and the results confirmed that the board certification policy is also effective for Asian population. The policy implications of these findings are discussed.     

Prevalence and correlates of objectively measured physical activity and sedentary behavior among US pregnant women

ObjectivePhysical activity is recommended for pregnant women without medical or obstetric complications. This study described the prevalence and correlates of objectively-measured physical activity and sedentary behavior among United States pregnant women.MethodsUsing cross-sectional data collected from the 2003 to 2006 National Health and Nutrition Examination Survey (NHANES), 359 pregnant women ≥16 years wore an accelerometer for 1 week.ResultsWomen participated in a mean of 12.0 minutes/day (standard error (SE) 0.86) of moderate activity and 0.3 minutes/day (SE 0.08) of vigorous activity. Mean moderate to vigorous physical activity varied by trimester: 11.5 minutes/day in first trimester, 14.3 minutes/day in second trimester, and 7.6 minutes/day in third trimester. On average, women spent 57.1% of their monitored time in sedentary behaviors. In multivariable adjusted models, moderate to vigorous physical activity was higher in the first (p = 0.02) and second (p < 0.001) trimesters compared to the third trimester, and among women with higher household income (p = 0.03) compared to lower household income. In multivariable adjusted models, average counts/minute was higher in the second compared to the third trimester (p = 0.04).ConclusionMost pregnant women spent more than half of the monitored day in sedentary behaviors and did not meet recommendations for physical activity.     

Effects of dietary polyamines at physiologic doses in early-weaned piglets

ObjectivePolyamines are essential for many cell functions, and they form part of the composition of maternal milk; despite this, their addition to infant formulas is currently under evaluation. The aim of the present study was to evaluate the effects of milk formulas designed to resemble sow milk supplemented with polyamines at maternal physiologic milk doses on the gut maturation of early-weaned piglets.MethodsWe fed 30 newborn piglets with maternal milk (n = 10), a control milk formula (n = 10), or a milk formula supplemented with polyamines (5 nmol/mL of spermine and 20 nmol/mL of spermidine, n = 10) for 13 d (day 2 after birth through day 15). Several growth and intestinal development parameters were measured.ResultsThe piglets fed the formula containing polyamine at physiologic doses showed significantly increased crypt depth in the small intestine compared with those fed with the control formula. Villus length was correlated to crypt depth. Although there were no differences in the disaccharidase activities between the animals fed the two formulas, alkaline phosphatase and γ-glutamyl transferase activities tended to be higher in the jejunum of those fed the polyamine-supplemented diet. Dietary polyamines did not significantly modify the gut mucosal concentrations of putrescine, spermine, or spermidine.ConclusionMilk formulas supplemented with polyamines at maternal milk physiologic doses slightly enhanced gut growth and maturation in neonatal piglets.     

Hearing, mobility, and pain predict mortality: a longitudinal population-based study

ObjectiveMeasures of health-related quality of life (HRQL), including the Health Utilities Index Mark 3 (HUI3) are predictive of mortality. HUI3 includes eight attributes, vision, hearing, speech, ambulation, dexterity, cognition, emotion, and pain and discomfort, with five or six levels per attribute that vary from no to severe disability. This study examined associations between individual HUI3 attributes and mortality.Study Design and SettingBaseline data and 12 years of follow-up data from a closed longitudinal cohort study, the 1994/95 Canadian National Population Health Survey, consisting of 12,375 women and men aged 18 and older. A priori hypotheses were that ambulation, cognition, emotion, and pain would predict mortality. Cox proportional hazards regression models were applied controlling for standard determinants of health and risk factors.ResultsSingle-attribute utility scores for ambulation (hazard ratio [HR] = 0.10; 0.04–0.22), hearing (HR = 0.18; 0.06–0.57), and pain (HR = 0.53; 0.29–0.96) were statistically significantly associated with an increased risk of mortality; ambulation and hearing were predictive for the 60+ cohort.ConclusionFew studies have identified hearing or pain as risk factors for mortality. This study is innovative because it identifies specific components of HRQL that predict mortality. Further research is needed to understand better the mechanisms through which deficits in hearing and pain affect mortality risks.     

Quality and usefulness of an anonymous unique personal identifier to link hospital stays recorded in French claims databases

BackgroundsSince 2001, the French national case mix program is allowed by law to use an enciphering algorithm named “FOIN” to produce a unique anonymous identifier in order to crosslink, within and across hospitals, discharge abstracts from a given patient. This algorithm “thrashes” the person's health insurance number, date of birth and gender. Before using information produced by the case mix program, either for case mix payment or for epidemiology research or for assessing care approaches, the quality of linkage must be evaluated.MethodsFoin error flags were first assessed in the 2002 Rhône-Alpes regional case mix database. Second, for the two university hospitals of Lyon and Saint-Etienne, double identifiers (two or more Foin identifiers for the same patient) and collisions (a single Foin identifier for at least two patients) were compared with others identifiers: administrative identifier and an anonymous identifier produced by Anonymat^® software from name, forename and date of birth. Third, Foin error flags are crossed with Foin double identifier or collision mistakes.ResultsFirst, among 1 668 971 hospital discharge abstracts from the regional case mix database, 206 710 (12.4%) had at least one Foin error flag. The most frequent error flag (93 026 [5.5%] stays) was due to the lack of the three identifying variables. The greatest number for error flags concerned the stays of newborns (38.5%) and those of public hospitals (17.3%). Second, Foin created a few double identifiers: 1.2% among 137 236 patients from university hospital of Lyon and 0.3% among 39 512 patients from university hospital of Saint-Etienne. The collisions concerned 7776 (5.7%) patients from Lyon and 460 (1.2%) from Saint-Etienne. The identifier produced by Anonymat performed better than the one produced by Foin: 99.6% from the two university hospitals. Third, less than 3% of stays without Foin error flag nevertheless had mistakes on Foin when compared with others identifiers.ConclusionThe overall assessment is not in favour of a quality threshold using the Foin identifier on a routine basis except in some areas and if certain activities like neonatology are excluded. There are several ways to improve the linkage of health data.     

Caractéristiques des centres de santé et conseils prénatals de préparation à la naissance

AimCounseling relating to birth preparedness is an essential component of the WHO Focused Antenatal Care model. During the antenatal visits, women should receive the information and education they need to make choices to reduce maternal and neonatal risks. The objective of this study conducted among women attending antenatal visits in rural Burkina Faso was to search for a link between the characteristics of the center delivering the health care and the probability of being exposed to information and advice relating to birth preparedness.MethodsA multilevel study was performed using survey data from women (n = 464) attending health centres (n = 30) in two rural districts in Burkina Faso (Dori and Koupela). The women were interviewed using the modified questionnaire of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO).ResultsWomen reported receiving advice about institutional delivery (72%), signs of danger (55%), cost of institutional delivery (38%) and advice on transportation in the event of emergency (12%). One independent factor was found to be associated with reception of birth preparedness advice: number of antenatal visits attended. Compared with women from Dori, women from Koupela were more likely to have received information on signs of danger (OR = 3.72; 95%CI: 1.26–7.89), institutional delivery (OR = 4.37; 95%CI: 1.70–10.14), and cost of care (OR = 3.01; 95%CI: 1.21–7.46). The reduced volume of consultations per day and the availability of printed materials significantly remain associated with information on the danger signs and with the institutional delivery advices. Comparison by center activity level showed that women attending health centers delivering less than 10 antenatal visits per day were more likely to receive information on signs of danger (OR = 2.63; 95%CI: 1.12–6.24) and to be advised about institution delivery (OR = 6.30; 95%CI: 2.47–13.90) compared to health centers delivering more than 20 antenatal visits per day. Women attending health centres equipped with printed materials (posters, illustrated documents) were more likely to receive information on signs of danger (OR = 4.25; 95%CI: 1.81–12.54) and be advised about institutional delivery (OR = 6.85; 95%CI: 3.17–14.77).ConclusionEfforts should be made to reach women with birth preparedness messages. Rural health centres in Burkna Faso need help to upgrade their organizational services and provide patients with printed materials so they can improve antenatal care delivery.     

Using short information leaflets as recruitment tools did not improve recruitment: a randomized controlled trial

ObjectiveTo assess if the type of patient information leaflet (PIL) received at an initial invitation to participate in a randomized trial influences the number of patients recruited.Study Design and SettingA randomized controlled trial was used to compare the effects of short or full PILs on recruitment in a primary care setting. Patients invited to take part in the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy study through a database mail out were randomly allocated to receive one of two types of PIL.ResultsThe type of PIL received with the initial invitation did not influence recruitment. Of those receiving the short PIL, 5.4% were recruited compared with 5.1% in the full PIL group. The difference in proportions between the groups was not statistically significant (mean difference = 0.3%; 95% confidence interval [CI] = ?1.5%, 2.2%; P = 0.75). Secondary analyses on the numbers of ineligible patients showed a statistically significant difference between the groups in favor of the full PIL group, which yielded fewer ineligible patients (P = 0.04; mean difference = 1.4%; CI = 0.03%, 2.8%).ConclusionProviding patients with shorter PILs when inviting them to participate in research does not affect the numbers who are subsequently recruited and yields more ineligible patients. Therefore, it is recommended to use the full PIL as a recruitment tool.     

Cada semana cuenta: uso de dispositivos sanitarios y costes relacionados de una cohorte comunitaria de personas con enfermedades crónicas avanzadas

ObjectiveTo describe the use of health resources of people with advanced chronicity, quantifying and characterizing its cost to suggest improvements in health care models.DesignObservational, analytical and prospective study during 3 years of a cohort of people with advanced chronicity.LocationThree primary care teams (EAP) of Osona, Cataluña.Participants224 people identified as advanced patients through a systematic population strategy.Main measurementsAge, sex, type of home, end-of-life trajectory; use, type and cost of resources in primary care, emergencies, palliative teams or hospitalization (in acute or intermediate care).ResultsPatients made an average of 1.1 admissions per year (average stay = 6 days), 74% in intermediate care hospitals. They lived in the community 93.4% of time, carrying out 1 weekly contact with the EAP (45.1% home care). The average daily cost was 19.4 euros, the main chapters were intermediate care hospitalizations (36.5%), EAP activity (29.4%) and admissions in acute hospitals (28.6%). Factors determining a potential lower cost are frailty/dementia as trajectory (p < 0.001), living in a nursing-home facility (p < 0.001) and over-aging (p < 0.001). There are certain differences in the behavior of the EAP related to the global cost and to community resources (p < 0.05).ConclusionsConsumption in intermediate hospitalization and primary care is more relevant than stays in acute care centers. Nursing-homes and home-care strategies are important to attend effectively and efficiently, especially when primary care teams get ready for it.     

Impact of socioeconomic status on stage at diagnosis of breast cancer

BackgroundThis study aimed to evaluate the potential impact of social inequalities on stage at diagnosis and long-term outcome of breast cancer patients attending the Institut Curie in Paris (France).MethodsThe study population included 14,610 breast cancer patients diagnosed and treated in the Institut Curie between 1981 and 2001. The socioeconomic status was determined from district of residence, median income for town of residence corrected by the consumption unit and body mass index. Logistic regression models adjusted on socioeconomic factors were used to evaluate clinical and pathologic features at diagnosis. Overall survival and distant metastasis were analysed with log-rank tests and Cox proportional hazards regression models.ResultsPatients living in lower income districts were more likely to be diagnosed with breast tumors size greater than 20 mm (P = 0.01). Residents of high-income urban areas (> 15,770 €) exhibited a significant overall survival and distant metastasis advantage (respectively HR = 0.93 [0.86–0.99]; P = 0.02 and HR = 0.91 [0.85–0.98]; P = 0.01). Breast cancer screening with mammography was independent of district of residence (P = 0.61) or income (P = 0.14). After adjusting for age at diagnosis and period, the risk of having breast cancer with unfavorable prognostic factors such as tumor size greater than 20 mm decreased with 1000 € increase in district income (OR = 0.986 [0.98–0.99]; P < 0.001). Similarly, the risk of cancer death decreased for patients residing in districts with median income greater than 15,770 € (HR = 0.92 [0.86–0.98]; P = 0.01).ConclusionDespite the limitations of the study (aggregate data used to assess socioeconomic status, non representative cohort of French women), we observed that poorer breast cancer prognosis with advanced disease diagnosis and increased risk of breast cancer mortality was related to low socioeconomic status.     

An assessment of the effectiveness of growth monitoring and promotion practices in the Lusaka district of Zambia

ObjectiveWe evaluated the effectiveness of the growth monitoring and promotion (GMP) program in Zambia.MethodsA 3-mo prospective study of growth outcomes was undertaken at randomly selected health facilities and community posts within the Lusaka district. Children <2 y old (n = 698) were purposively sampled from three health facilities (n = 459) and four community posts (n = 77) where health workers had undergone training in GMP and three health facilities where staff had not received training (n = 162). Qualitative data on knowledge, attitudes, and practices of GMP were collected from health facility managers (n = 6), health workers (n = 35), and mothers whose children attended all follow-up visits (n = 27).ResultsAnthropometric status of children in all groups deteriorated, with children at community posts having the worst outcomes (change in weight-for-age Z-score ?0.8 ± 0.7), followed by trained (?0.5 ± 0.6) and untrained (–0.3 ± 0.47; P < 0.05) health facilities. A similar trend was seen for weight for length. The overall dropout rate was 74.1%. Weight-for-age Z-scores were higher at 1- and 2-mo follow-up visits for children who did not complete the study at trained health facilities and community posts compared with those who remained in the study. Mothers/caregivers identified GMP as important in attending the under-five clinic, associated their child's weight with overall health status, and expressed a willingness to comply with health workers' advice. However, health care providers were poorly motivated, inadequately supervised, and demonstrated poor practices.ConclusionsThe GMP program in Lusaka is functioning suboptimally, even in facilities with trained staff.     

Author's specialty and conflicts of interest contribute to conflicting guidelines for screening mammography

ObjectiveTo examine the relationship between guideline panel members’ conflicts of interest and guideline recommendations on screening mammography in asymptomatic, average-risk women aged 40–49 years.Study Design and SettingWe searched the National Guideline Clearinghouse and MEDLINE for relevant guidelines published between January 2005 and June 2011. We examined the disclosures and specialties of the lead and secondary authors of these guidelines, as well as the publications of the lead authors.ResultsTwelve guidelines were identified with a total of 178 physician authors from a broad range of specialties. Of the four guidelines not recommending routine screening, none had a radiologist member, whereas of the eight guidelines recommending routine screening, five had a radiologist member (comparison of the proportions, P = 0.05). A guideline with radiologist authors was more likely to recommend routine screening (odds ratio = 6.05, 95% confidence interval = 0.57–∞, P = 0.14). The proportion of primary care physicians on guideline panels recommending routine vs. nonroutine screening was significantly different (38% vs. 90% of authors; P = 0.01). The odds of a recommendation in favor of routine screening were related to the number of recent publications on breast disease diagnosis and treatment by the lead guideline author (P = 0.02).ConclusionRecommendations regarding mammography screening in this target population may reflect the specialty and intellectual interests of the guideline authors.     

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

ObjectivesAdjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations.Study Design and SettingRetrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance.ResultsNine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individual's QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index.ConclusionA simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.