Treatment seeking behaviour and costs due to acute and chronic forms of lymphatic filariasis in urban areas in south India

Previous estimates on the economic burden of lymphatic filariasis (LF) in India and elsewhere were primarily based on studies in rural areas. We investigated the treatment costs due to acute and chronic forms of LF in urban areas, where nearly one-third of the affected people live. Almost 98% of the patients with acute episodes of adenolymphangitis (ADL) underwent treatment and 49% of chronic patients also received treatment. The average treatment cost per ADL episode (n = 108) was Rs 22.21 +/- 53.84 (US dollars 0.46 +/- 1.12). The overall (n = 200) treatment costs incurred by a chronic patient per visit were Rs 16.71 +/- 62.36 (US dollars 0.35 +/- 1.30); for those who paid (n = 98) they were Rs 34.10 +/- 85.90 (US dollars$ 0.71 +/- 1.79). These costs are considerably higher than in rural areas. Government health centres and private practitioners were important sources of treatment. Treatments received from private practitioners were considerably more expensive than those from government health facilities. The cost of medicine accounted for 44% and 50% of the total expenditure on treatment for acute and chronic disease patients, respectively. The medical personnel from these treatment sources need to be trained on the new morbidity management methods, which are likely to be more effective than the current methods of treatment.     

Choosing between public and private or between hospital and primary care: responsiveness, patient-centredness and prescribing patterns in outpatient consultations in Bangkok

OBJECTIVE: To document differences in provider behaviour between private and public providers in hospital outpatient departments, health centres and clinics in Bangkok, Thailand. METHOD: Analysis of the characteristics of 211 taped consultations with simulated patients. RESULTS: Private hospitals and clinics were significantly more responsive. Private clinics but not private hospitals were also significantly more patient-centred. All doctors, but particularly those in private hospitals, prescribed unnecessary and potentially harmful technical investigations and drugs. The direct cost to the patient varied between 1.5 (in public health centres) and 12 (in private hospitals) times the minimum daily wage. The combined cost--to the patient and to the state--in public hospitals and health centres exceeded the cost of consultations in private clinics. CONCLUSION: Market incentives favour responsiveness and a patient-centred approach, but not more appropriate therapeutic decisions. Excessive use of pharmaceuticals is observed among public as well as private providers, but is most pronounced in private hospitals. If patients in Bangkok want to maximize responsiveness and degree of patient-centred care and yet minimize costs and iatrogenesis, they would benefit from avoiding hospitals, both public and private, and, to a lesser extent, specialists. Choosing to use primary facilities, health centres and clinics, particularly when consultations are carried out by general practitioners (GPs), is more beneficial than choosing between public and private providers.     

Providers' Awareness of HIV Testing Policies and Perceived Testing Practices

The objective of this study was to examine providers' awareness of state guidelines regarding HIV testing of pregnant women and their perceptions of access to care for HIV-positive pregnant women. State health departments, county health clinics, and other health care practitioners (private physicians, nurse practitioners, and health educators) were surveyed regarding awareness of state policies on HIV testing, particularly of pregnant women, as well as perceptions of current practices in the care of HIV-positive pregnant women. About two thirds of state offices of public health (70%), county public health providers (62.7%), and private providers (66.7%) were able accurately to describe the HIV reporting policy of their state, and providers across settings perceived that only about half of pregnant women were being provided with information regarding the prevention of vertical transmission during pregnancy. A mechanism is needed to routinely update public health departments and providers regarding state HIV reporting policies.     

Sharp injuries and their determinants among health care workers at first‐level care facilities in Sindh Province,Pakistan

Objectives To assess the rate and determinants of sharp injuries during the previous 6 months among health care workers at first‐level care facilities in two districts of Pakistan. Methods Cross‐sectional survey at public, general practitioners and non‐licensed private practitioners selected through stratified random sampling. At each facility, we interviewed a prescriber and a dispenser/injection provider about knowledge of bloodborne pathogens transmission and preventive practices, risk perception, and use of precautions and sharp injuries received during the previous 6 months. Multivariable Poisson regression was used to assess the factors associated with the number of sharp injuries. Results Fifty‐four percentage of the 233 workers had at least one injury during the previous 6 months. The overall rate of sharp injuries per person per year was 3.7; among non‐physician prescribers (9%), it was 4.3; among dispensers (69%), it was 3.7, and among physicians (18%), it was 2.1. In the multivariable model, work experience, risk perception and type of health care worker were significantly associated with receiving sharp injuries during the previous 6 months. In the model including dispensers only, a higher knowledge score was associated with fewer sharp injuries, while perceived severity of disease and lack of professional qualification were associated with more. Conclusions Sharp injuries are common in Pakistan. Better knowledge about modes of bloodborne pathogen transmission and professional qualification may reduce their incidence.     

Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia

OBJECTIVES: To document how out-of-pocket health expenditure can lead to debt in a poor rural area in Cambodia. METHODS: After a dengue epidemic, 72 households with a dengue patient were interviewed to document health-seeking behaviour, out-of-pocket expenditure, and how they financed such expenditure. One year later, a follow-up visit investigated how the 26 households with an initial debt had coped with it. RESULTS: The amount of out-of-pocket health expenditure depended mostly on where households sought care. Those who had used exclusively private providers paid on average US dollars 103; those who combined private and public providers paid US dollars 32, and those who used only the public hospital US dollars 8. The households used a combination of savings, selling consumables, selling assets and borrowing money to finance this expenditure. One year later, most families with initial debts had been unable to settle these debts, and continued to pay high interest rates (range between 2.5 and 15% per month). Several households had to sell their land. CONCLUSIONS: In Cambodia, even relatively modest out-of-pocket health expenditure frequently causes indebtedness and can lead to poverty. A credible and accessible public health system is needed to prevent catastrophic health expenditure, and to allow for other strategies, such as safety nets for the poor, to be fully effective.     

Ambulatory medical care in Mexico: the cost for users

OBJECTIVE: To analyze the results of the National Health Survey (ENSA-II) as to the costs generated by the search and obtainment of ambulatory medical attention in various institutions of the private and public health sector. MATERIAL AND METHODS: Information was raised from the health care cost indicators reported by the study population of the ENSA-II. The dependent variable was the direct expense for the consumer and the independent variables, the condition of being insured and the income. Variation significance levels were identified using the test by Duncan. RESULTS: The costs at national level in US dollar were: transport $2.20, medical visit $7.90, drugs $9.60, diagnostic studies $13.6; average total cost for ambulatory attention was $22.70. Empirical finding suggest a new direct and indirect cost-for-consumer analysis for the health care users. These costs represent an important burden on the family income, which worsens when users are not insured. CONCLUSIONS: Incorporation of the economic perspective to the analysis of public health issues should not be limited to the analysis of the health provider's expenses, particularly if the problems of equity and accessibility must be solved, which are at present characteristic of health care services in Mexico.     

Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India.

OBJECTIVES: To investigate the factors associated with delay in 1) care-seeking (patient delay), and 2) diagnosis by health providers (health system delay), among smear-positive tuberculosis patients, before large-scale DOTS implementation in South India. METHODS: New smear-positive patients were interviewed using a structured questionnaire. RESULTS: Among 531 participants, the median patient, health system and total delays were 20, 23 and 60 days, respectively. Twenty-nine per cent of patients delayed seeking care for > 1 month, of whom 40% attributed the delay to their lack of awareness about TB. Men postponed seeking care for longer periods than women (P = 0.07). In multivariate analysis, the patient delay was greater if the patient had initially consulted a government provider (adjusted odds ratio [AOR] 2.2, P < or = 0.001), resided at a distance >2 km from a health facility (AOR 1.6, P = 0.04), and was an alcoholic (AOR 1.6, P = 0.04). Health system delay was >7 days among 69% of patients. Factors associated with health system delay were: first consultation with a private provider (AOR 4.0, P < 0.001), a shorter duration of cough (AOR 2.6, P = 0.001), alcoholism (P = 0.04) and patient's residence >2 km from a health facility (AOR 1.8, P = 0.02). The total delay resulted largely from a long patient delay when government providers were consulted first, and a long health system delay when private providers were consulted first. CONCLUSION: Public awareness about chest symptoms and the availability of free diagnostic services should be increased. Government and private physicians should be educated to be aware about the possibility of tuberculosis when examining out-patients. Effective referrals for smear microscopy should be developed between private and public providers.     

Adherence to Long-Acting Bronchodilators After Discharge for COPD: How Much of the Geographic Variation is Attributable to the Hospital of Discharge and How Much to the Primary Care Providers?

In moderate–severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007–2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially ‘reflect’ the clinical approach of hospitals of discharge.     

Longer delays in tuberculosis diagnosis among women in Vietnam.

SETTING: Study conducted in 23 randomly selected districts in four provinces of Vietnam. OBJECTIVE: To describe and compare health seeking behaviour between men and women and to measure delays in tuberculosis (TB) diagnosis. DESIGN: All patients (n = 1027) aged 15-49 years with new smear-positive pulmonary TB detected in the selected districts during 1996 were interviewed using a structured questionnaire. RESULTS: Mean total delay to TB diagnosis was 13.3 weeks (95% confidence interval [CI] 11.5, 15.1) for women and 11.4 weeks (95% CI 10.6, 12.2) for men, including a patient's delay of 7.9 weeks (95% CI 6.5, 9.3) and 7.6 weeks (95% CI 6.9, 8.3) respectively. Doctor's delay was significantly longer among women (5.4 weeks, 95% CI 4.2, 6.6) than among men (3.8 weeks, 95% CI 3.3, 4.3). Women did not start seeking care later than men, nor did they have a different health seeking pattern. Women visited more health care providers than men (1.7 and 1.5 providers, respectively, P = 0.02). CONCLUSION: Patient's delay is unacceptably long for both men and women. Women do not receive a diagnosis of TB by doctors or other health care providers as quickly as men once they seek health care. The reasons for this gender difference warrant further investigations.     

Long‐Term Retention of Older Adults in the Cardiovascular Health Study: Implications for Studies of the Oldest Old

OBJECTIVES: To describe retention according to age and visit type (clinic, home, telephone) and to determine characteristics associated with visit types for a longitudinal epidemiological study in older adults. DESIGN: Longitudinal cohort study. SETTING: Four U.S. clinical sites. PARTICIPANTS: Five thousand eight hundred eighty‐eight Cardiovascular Health Study (CHS) participants aged 65 to 100 at 1989/90 or 1992/93 enrollment (58.6% female; 15.7% black). CHS participants were contacted every 6 months, with annual assessments through 1999 and in 2005/06 for the All Stars Study visit of the CHS cohort (aged 77–102; 66.5% female; 16.6% black). MEASUREMENTS: All annual contacts through 1999 (n=43,772) and for the 2005/06 visit (n=1,942). RESULTS: CHS had 43,772 total participant contacts from 1989 to 1999: 34,582 clinic visits (79.0%), 2,238 refusals (5.1%), 4,401 telephone visits (10.1%), 1,811 home visits (4.1%), and 740 other types (1.7%). In 2005/06, the All Stars participants of the CHS cohort had 36.6% clinic, 22.3% home, and 41.1% telephone visits. Compared with participants aged 65 to 69, odds ratios of not attending a CHS clinic visit were 1.82 (95% confidence interval (CI)=1.54–2.13), 2.94 (95% CI=2.45–3.57), 4.55 (95% CI=3.70–5.56), and 9.09 (95% CI=7.69–11.11) for those aged 70 to 74, 75 to 79, 80 to 84, and 85 and older, respectively, in sex‐adjusted regression. In multivariable regression, participants with a 2005/06 clinic visit were younger, more likely to be male and in good health, and had had better cognitive and physical function 7 years earlier than participants with other visit types. Participants with home, telephone, and missing visits were similar on characteristics measured 7 years earlier. CONCLUSION: Offering home, telephone, and proxy visits are essential to optimizing follow‐up of aging cohorts. Home visits increased in‐person retention from 36.5% to 58.8% and diversified the cohort with respect to age, health, and physical functioning.     

Treatment preferences,return visit planning and factors affecting hypertension practice amongst general practitioners and internal medicine specialists (The General Practitioner Hypertension Practice Study)

Abstract. Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists. Design. Mailed case report questionnaires. Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments. Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice. Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization. Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.     

Socio-economic impact of tuberculosis on patients and family in India.

OBJECTIVE: To quantify the socio-economic impact of tuberculosis on patients and their families from the costs incurred by patients in rural and urban areas. DESIGN: An interview schedule prepared from 17 focus group discussions was used to collect socio-economic demographic characteristics, employment, income particulars, expenditure on illness and effects on children from newly detected sputum-positive pulmonary tuberculosis patients. The direct and indirect costs included money spent on diagnosis, drugs, investigations, travel and loss of wages. Total costs were projected for the entire 6 months of treatment. RESULTS: The study population consisted of 304 patients (government health care 202, non governmental organisation 77, private practitioner 25), 120 of whom were females. Mean direct cost was Rs.2052/-, indirect Rs.3934/-, and total cost was Rs.5986/- ($171 US). The mean number of work days lost was 83 and mean debts totalled Rs.2079/-. Both rural and urban female patients faced rejection by their families (15%). Eleven per cent of schoolchildren discontinued their studies; an additional 8% took up employment to support their family. CONCLUSIONS: The total costs, and particularly indirect costs due to TB, were relatively high. The average period of loss of wages was 3 months. Care giving activities of female patients decreased significantly, and a fifth of schoolchildren discontinued their studies.     

French general practitioners' attitudes toward therapeutic advances in HIV care: results of a national survey

We aimed to assess attitudes to French primary care providers towards recent advances in HIV care. Telephone surveys in a random sample of French general practitioners (GPs) were carried out in April 1996 (response rate=70.3%; n=1186). Only 40.5% of the sample had participated in the regular medical follow-up of HIV-infected patients during the previous year. Among these 480 respondents, only a few (13.3%) declared that they would take care of an asymptomatic patient with a high (>500 cells/mm3) CD4 count as the unique provider. A majority (66.2%) had referred at least one HIV-infected patient to a hospital specialist in the previous year. A total of 31.4% declared that they considered it appropriate for an antiretroviral treatment to be initiated to an asymptomatic patient with 300 CD4 cells/mm3, and only 23.5% were already in favour of combination therapies rather than zidovudine monotherapy as treatment of choice. GPs with the most experience with HIV care tended to be the most reluctant to modify their attitude in favour of earlier initiation of antiretroviral therapies and of the switch from monotherapy to combination therapies. The survey suggests there is a gap between attitudes of GPs and those of AIDS specialists toward preliminary reports of therapeutic advances in HIV care. Whether or not such a gap may create problems for an appropriate diffusion of new antiretroviral therapies should be carefully monitored, in the context of current reforms emphasizing the key role of primary providers in most health-care systems.     

Cost-effectiveness of impedance cardiography testing in uncontrolled hypertension

To evaluate the short- and long-term cost-effectiveness of impedance cardiography (ICG) testing in uncontrolled hypertensives, we analyzed the Consideration of Noninvasive Hemodynamic Monitoring to Target Reduction of Blood Pressure Levels (CONTROL) trial results that compared the blood pressure-lowering effects of standard vs ICG care. Short-term cost-effectiveness was evaluated as the incremental cost per incremental mm Hg reduced during the trial. Long-term cost-effectiveness was evaluated as incremental cost per quality-adjusted life-year gained over 10 years. ICG care short-term cost-effectiveness was 20 US dollar per incremental mm Hg reduced for systolic blood pressure (vs standard care, 36 US dollar per mm Hg reduced) and 23 US dollar per incremental mm Hg reduced for diastolic blood pressure (vs standard care, 79 US dollar per mm Hg reduced). In the long term, ICG resulted in a 476 US dollar cost savings and 0.109 quality-adjusted life-years gained per patient (-4,371 US dollar per quality-adjusted life-year gained, sensitivity analysis -8,764 to 13,163 US dollar). The use of ICG testing to reduce blood pressure in uncontrolled hypertensive patients is cost-effective from both a short- and long-term perspective.     

Different views of health care professionals on the treatment of osteoarthritis including low back pain

SIR, In surveying the views of health care professionals onthe treatment of osteoarthritis, Chard et al. [1] observed interalia that general practitioners (GPs) were more likely to usecomplementary therapy. Many GPs in Germany undertake approvedfurther education in     

Influence of discipline of provider and model of care on an arthritis educational intervention in primary care

Objective

To identify both provider and organizational characteristics that predicted outcomes following an educational intervention (9‐hour workshop and followup reinforcement activities) developed to improve the management of arthritis in primary care.

Methods

Providers completed a survey at baseline and at 6 months postworkshop, including a case scenario for early rheumatoid arthritis. Providers were asked how they would manage the case and their responses were coded to calculate a best practice score, ranging from 0–7. Two‐level hierarchical linear modeling was used to determine which of the measured provider and organizational factors predicted best practice scores at followup.

Results

A total of 275 multidisciplinary providers from 131 organizations completed both baseline and followup surveys. Best practice scores increased by 17% (P < 0.01); however, the mean score at 6‐month followup remained relatively low (2.68). Significant predictors of best practice scores at followup were discipline of provider and model of primary care in which they worked (P < 0.05), adjusting for baseline practice scores and clustering of providers within organizations. Physicians, nurse practitioners, and rehabilitation therapists scored higher than nurses, students, and other health care providers (P < 0.01). Physician networks scored significantly lower than providers from multidisciplinary‐oriented models of care (P = 0.02).

Conclusion

These results have implications for the education of health professionals and the design of models of care to enhance arthritis care delivery.     

Aging and oral health related to quality of life in geriatric patients

Oral health is more than healthy teeth. Oral diseases and disorders can affect general health, well-being, and quality of life. The goal of this investigation was to establish oral health related to quality of life of geriatric patients. The study was made for a period of 12 months in a private dental office in Sofia, Bulgaria. It included 53 geriatric patients (36 women and 17 men). The women's average age was 69.5 years old (65 to 87), and men's average age was 70.5 years old (65 to 84). A special questionnaire was made and patients were asked about specific dental problems related to quality of life. Of the respondents, 69.8% were women and only 30.2% were men, which means that women are more likely to visit dental health care offices. Of geriatric patients, 31.5% visit the dental office because of acute pain and 68.4% because of caries. The following are the specific items used to assess geriatric oral health and quality of life: trouble biting or chewing (eating), uncomfortable eating in front of other people, trouble speaking, and limitation of social contacts. Oral health can be an indicator of general health and quality of life in geriatric patients. Oral diseases are progressive and cumulative. They become more complex over time. Improved oral health will allow geriatric patients to improve their self-confidence, have active social contacts, and restore the ability to work at home or on the job.     

Consultations with complementary and alternative medicine practitioners amongst wider care options for back pain: a study of a nationally representative sample of 1,310 Australian women aged 60–65 years

Back pain is a significant health service issue in Australia and internationally. Back pain sufferers can draw upon a range of health care providers including complementary and alternative medicine (CAM) practitioners. Women are higher users of health services than men and tend to use CAM frequently for musculoskeletal conditions. However, there remain important gaps in our understanding of women’s consultation patterns with CAM practitioners for back pain. The objective of this study is to examine the prevalence of use and characteristics of women who use CAM practitioners for back pain. The method used was a survey of a nationally representative sample of women aged 60–65 years from the Australian Longitudinal Study on Women’s Health. Women consulted a massage therapist (44.1 %, n?=?578) and a chiropractor (37.3 %, n?=?488) more than other CAM practitioners for their back pain. Consultations with a chiropractor for back pain were lower for women who consulted a General Practitioner (GP) (OR, 0.56; 95 % CI 0.41, 0.76) or a physiotherapist (OR, 0.53; 95 % CI 0.39, 0.72) than for those who did not consult a GP or a physiotherapist. CAM practitioner consultations for back pain were greater for women who visited a pharmacist (OR, 1.99; 95 % CI 1.23, 3.32) than for women who did not visit a pharmacist. There is substantial use of CAM practitioners alongside conventional practitioners amongst women for back pain, and there is a need to provide detailed examination of the communication between patients and their providers as well as across the diverse range of health professionals involved in back pain care.     

Predictive validity of the RIASI: alcohol and drug use and problems six months following remedial program participation

The ability of screening instruments for convicted drinking drivers to predict subsequent alcohol and drug-related problems rarely has been studied. The predictive validity of the Research Institute on Addictions Self-Inventory (RIASI) was investigated in a sample of 6,003 convicted drinking drivers who were participating in Back on Track (BOT), Ontario's remedial measures program for convicted drinking drivers. All BOT participants complete an assessment (which includes the RIASI), followed by a brief education or treatment program, and concluded 6 months later by a follow-up interview. The follow-up interview collects information on self-reported alcohol and other drug use and problems, and contacts with other health care providers in the 90 days prior to the follow-up contact. The ability of scores on the RIASI to predict these measures was assessed. The results revealed that, for almost all comparisons, individuals who used alcohol and other drugs, reported more substance-related problems at follow-up, and reported more contacts with other health and addictions providers had significantly higher scores on the RIASI total score and the RIASI recidivism scale at the initial assessment. The data indicate that this instrument appears to be able to identify individuals who will experience alcohol and drug related problems in the future.     

Predictive Validity of the RIASI: Alcohol and Drug Use and Problems Six Months Following Remedial Program Participation

The ability of screening instruments for convicted drinking drivers to predict subsequent alcohol and drug-related problems rarely has been studied. The predictive validity of the Research Institute on Addictions Self-Inventory (RIASI) was investigated in a sample of 6,003 convicted drinking drivers who were participating in Back on Track (BOT), Ontario's remedial measures program for convicted drinking drivers. All BOT participants complete an assessment (which includes the RIASI), followed by a brief education or treatment program, and concluded 6 months later by a follow-up interview. The follow-up interview collects information on self-reported alcohol and other drug use and problems, and contacts with other health care providers in the 90 days prior to the follow-up contact. The ability of scores on the RIASI to predict these measures was assessed. The results revealed that, for almost all comparisons, individuals who used alcohol and other drugs, reported more substance-related problems at follow-up, and reported more contacts with other health and addictions providers had significantly higher scores on the RIASI total score and the RIASI recidivism scale at the initial assessment. The data indicate that this instrument appears to be able to identify individuals who will experience alcohol and drug related problems in the future.