Energy poverty and health: Trends in the European Union before and during the economic crisis, 2007–2016

The aim of this study is to analyse the time trends in the European Union (EU) before and during the economic crisis in 1) the energy poverty (EP) prevalence; 2) the association between EP and health and 3) the impact of EP on health. We analyse trends among women and men in two EU macro regions, defined by a novel index of structural vulnerability to EP. The study shows how EP and its impact on health worsened during the economic crisis and identifies groups at higher risk such as women and people living in Mediterranean and Eastern European countries, which have been found to be countries with higher structural vulnerability to EP.     

Changes in managed care activity in outpatient substance abuse treatment organizations, 1995–2000

Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further, it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased, with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care sector. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or, alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.     

Primary care reform in Manitoba,Canada, 2011–15: Balancing accountability and acceptability

Primary care reform cannot succeed without substantive change on the part of providers. In Canada, these are mostly fee-for-service physicians, who tend to regard themselves as independent professionals and not under managerial sway. Hence, policymakers must balance two conflicting imperatives: ensuring the acceptability of renewal efforts to these physicians while enforcing their accountability for defined actions or outcomes. In its 2011–15 strategy to improve access to primary care, the province of Manitoba introduced several linked initiatives, each striving to blend acceptability- and accountability-promoting elements. Clearly delimited initiatives that directly promoted a specific observable behaviour (accountability) through financial or non-financial support (acceptability) were most successfully implemented. System-wide initiatives with complicated designs (notably a primary care network model that established formal partnership among clinics and regional health authorities) encountered greater difficulties in recruiting and sustaining physician participation. Although such initiatives offered physicians considerable decision-making latitude (acceptability), many physicians questioned the meaningfulness of opportunities for voice within a predetermined structure (accountability). Moreover, policymakers struggled to enhance the acceptability of such initiatives without sacrificing strong accountability mechanisms. Policymakers must carefully consider how acceptability and accountability elements may interact, and design them in such a way as to minimize the risk of mutual interference.     

The Growth of Managed Care and Changes in Physicians' Incomes, Autonomy, and Satisfaction, 1991–1997

Using survey data collected in 1991 and 1997 from a panel of almost 1,500 physicians, we analyzed the relationship between changes in physicians' incomes, practice autonomy, and satisfaction, and the growth of HMOs and physicians' perceived financial incentives. Both the growth of HMOs and financial incentives to reduce services were significantly related to lower income growth, reductions in practice autonomy, and decreases in satisfaction. Changes in income and autonomy were both positively and significantly related to changes in satisfaction. Controlling for changes in income and autonomy, HMO growth was no longer significantly related to changes in satisfaction. Having a perceived financial incentive to reduce services remained a negative and significant determinant of the change in career satisfaction.     

Hematological malignancies: Incidence in Basse-Normandie,France, for 1997–2004

BackgroundThis study was designed to present the incidence of all the hematological malignancies in Basse-Normandie for 1997–2004. We extracted the data from the Registre régional des hémopathies malignes de Basse-Normandie (RRHMBN), a French registry which belongs to the Association of the French Cancer Registries (FRANCIM).MethodsAll the malignant hematological diseases were coded using the third edition of the International Classification for Oncologic Diseases (ICDO-3) and the ADICAP classification, a special version adapted in 2001 for hematology. A total of 5510 new cases of malignant hematological disorders were registered over the 1997–2004 period. No significant difference in incidence was detected for any of the departments making up the Basse-Normandie region (Calvados, Manche and Orne). In men, the most frequent malignant disorders were non-Hodgkin malignant lymphomas (NHML) followed by chronic lymphocytic leukemia and other mature neoplasms, myelodysplastic syndromes (MDS), multiple myelomas (MM), myeloproliferative syndromes (MPS), acute myeloid leukemias (AML), Hodgkin lymphomas (HL), Waldenström macroglobulinemia (WM), and acute lymphoblastic leukemia (ALL). In women, MM is the third most frequent hematological disorder after NHML and lymphocytic leukemia followed by other mature neoplasms, MPS, MDS, AML, HL, WM, and ALL. The other hematological disorders are very rare.ResultsWe provide the incidence for the main hematological disorders and for the first time present the incidence of the different subtypes of the HL and NHML, mature lymphoid neoplasms, MPD, and MDS. These results are useful for the organization and follow-up of medical care. The development of specialized hematology and active protocols can optimize the management of older patients. High-quality data remain necessary for continuous monitoring and research on patients with malignant hematological diseases.     

Changes in government spending on healthcare and population mortality in the European union, 1995–2010: a cross-sectional ecological study

Objective

Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries.

Design

Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted.

Setting and Participants

European Union countries 1995–2010.

Main outcome measures

Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality.

Results

A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient −0.1217, p = 0.0001), postneonatal mortality (coefficient −0.0499, p = 0.0018), one to five years of age mortality (coefficient −0.0185, p = 0.0002), under five years of age mortality (coefficient −0.1897, p = 0.0003), adult male mortality (coefficient −2.5398, p = 0.0000) and adult female mortality (coefficient −1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics.

Conclusions

Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.     

Changes in physical activity and heart rate variability in chronic neck–shoulder pain: monitoring during work and leisure time

Objectives

Neck–shoulder pain (NSP) is a common work-related musculoskeletal disorder with unclear mechanisms. Changes in physical activity and autonomic nervous system regulation may be involved in the pathogenesis of chronic NSP. The aim of the current study was to investigate autonomic regulation in relation to physical activity and perceived symptoms during work and leisure time among workers with chronic NSP (n = 29) as compared to a healthy control group (CON, n = 27).

Methods

Physical activity was objectively monitored for 7 days using accelerometry. Beat-to-beat heart rate was collected continuously for 72 h, with simultaneous momentary ratings of pain, stress, and fatigue. Duration of sitting/lying, standing and walking, number of steps, and energy expenditure were used as measures of physical activity. Heart rate variability (HRV) indices were extracted in time and frequency domains as reflecting autonomic regulation. Data were divided into work hours, leisure time, and sleep.

Results

The NSP group rated higher levels of stress and fatigue at work and leisure, and reduced sleep quality as compared to CON. Elevated heart rate and reduced HRV were found in NSP compared with CON, especially during sleep. The NSP group demonstrated a different pattern of physical activity than CON, with a lower activity level in leisure time. Higher physical activity was associated with increased HRV in both groups.

Conclusion

Changes in HRV reflected an autonomic imbalance in workers with chronic musculoskeletal pain. This can be explained by reduced physical activity in leisure time. Intervention studies aimed at increasing physical activity may shed further light on the association between autonomic regulation and physical activity in work-related NSP.     

Changes in mercury levels in harbor porpoises from the Bay of Fundy,Canada, and adjacent waters during 1969–1977

Mercury levels were studied in a sample of 146 harbor porpoises taken in the Bay of Fundy, Canada, and adjacent waters during 1969–77. Mean concentrations of total mercury recorded in 5-year old males (exemplifying sexually mature adults) were 1.12 ppm in axial muscle, 0.38 in cerebrum, 0.31 in cerebellum, 2.00 in kidney, and 15.7 in liver. Respective means in tissues of 5-year old females were 1.46, 0.42, 0.21 2.77 and 16.2 ppm. There was a clear correlation of increase in total Hg with age in the tissues examined. Except in the liver, mercury levels were less well correlated with weight and body length than with age. Hg levels were not significantly correlated (p > 0.05) with weight and lengthwithin age classes, except marginally in the case of liver (P 0.10). Hg in muscle was virtually all in the methylated form, but in liver only about 17% was methylated. The proportions in other tissues were intermediate (kidney about 41%, mam-mary gland about 46%, brain about 8 to 52%). Levels in liver were thought to be those giving the best indication of changes in background levels of mercury in the food chain. Significant changes in Hg tissue levels appear to have occurred during the 9-year study period. Liver Hg levels in both sexes decreased from 1970 to 1971, remained low for 3 years, increased again in 1974, and continued to do so in the years following. Data are presented suggesting that this also occurred in other tissues. Since there is no evidence of a change in diet in this period, we speculate that the decline in Hg levels could be correlated with a dominance of relatively mercury-poor Gulf Stream water in the Bay of Fundy approaches in 1971–73, as opposed to the usual dominance by waters of the Nova Scotia current.     

Was the economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia? A time–trend analysis for Japan,Hong Kong,South Korea,Taiwan, Singapore and Thailand

In 1997–1998 a widespread economic crisis hit the economies of many East/Southeast Asian countries; its impact on suicide rates across the region has not been systematically documented. We investigated the impact of the Asian economic crisis (1997–1998) on suicide in Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Suicide and population data for the period 1985–2006 were extracted from the World Health Organisation's mortality database and Taiwanese mortality statistics. Sex-specific age-standardised suicide rates for people aged 15 years or above were analysed using joinpoint regression. Trends in divorce, marriage, unemployment, gross domestic product (GDP) per capita and alcohol consumption were compared with trends in suicide rates graphically and using time-series analysis. Suicide mortality decreased in the late 1980s and early 1990s but subsequently increased markedly in all countries except Singapore, which had steadily declining suicide rates throughout the study period. Compared to 1997, male rates in 1998 rose by 39% in Japan, 44% in Hong Kong and 45% in Korea; rises in female rates were less marked. Male rates also rose in Thailand, but accurate data were incomplete. The economic crisis was associated with 10,400 more suicides in 1998 compared to 1997 in Japan, Hong Kong and Korea. Similar increases in suicide rates were not seen in Taiwan and Singapore, the two countries where the economic crisis had a smaller impact on GDP and unemployment. Time-series analyses indicated that some of the crisis's impact on male suicides was attributable to increases in unemployment. These findings suggest an association of the Asian economic crisis with a sharp increase in suicide mortality in some, but not all, East/Southeast Asian countries, and that these increases were most closely associated with rises in unemployment.     

Rates of admission for ambulatory care sensitive conditions in France in 2009–2010: trends,geographic variation,costs, and an international comparison

Background

Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.

Methods

We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.

Results

The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients’ use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.

Conclusions

Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

     

Fatal heroin-related overdose in San Francisco, 1997–2000: a case for targeted intervention

Heroin-related overdose is the single largest cause of accidental death in San Francisco. We examined demographic, location, nontoxicological, and toxicological characteristics of opiate overdose deaths in San Francisco, California. Medical examiner’s case files for every opioid-positive death from July 1, 1997, to June 30, 2000, were reviewed and classified as overdose deaths or other. Demographic variables were compared to two street-based studies of heroin users and to census data. From 1997 to 2000, of all heroin-related overdoses in San Francisco 47% occurred in low-income residential hotels; 36% occurred in one small central area of the city. In 68% of deaths, the victim was reportedly alone. When others were present between last ingestion of heroin and death, appropriate responses were rare. In three cases, police arrested the person who called emergency services or others present on the scene. We recommend the development of overdose response training targeted at heroin users and those close to them, including the staff of residential hotels.     

Health care costs during the last 12 months of life in Israel: estimation and implications for risk-adjustment

Accumulating research shows that decedents’ costs are high, they increase towards death, and they comprise a large proportion of total lifetime costs. The objectives of this paper are (i) to examine the Israeli pattern of medical care cost during the 12 months prior to death by gender, age, and chronic conditions, and (ii) to examine the implications of the results for the Israeli risk adjustment scheme. For the first objective, we used 12 month follow-up data on a cohort of decedents. For the second objective, we supplemented the data with a cross-section of enrollees (survivors and decedents in 2004). With regard to the first objective, we found that the broad Israeli patterns of cost match previous studies from other countries. With respect to the second objective, we argue that since the cost during the last 12 months of life is very high and is concentrated among relatively few persons, in order to prevent any adverse incentives caused by the combination of age-based risk adjustment and segmentation of end-of-life health care, death should be introduced into the existing retrospective risk-sharing arrangement.