A prospective study of access to medical services following a community-based screening program

Participants in a multiphasic screening program, 454 men and 767 women, were followed up for a period of several months (117 days on the average) in order to evaluate their needs for medical services after screening. Five hundred sixty-two (47.1%) visited outpatient clinics in the study area; 185 as continuing visits for existing diseases (prevalent), 167 because of symptoms which developed after the screening (clinical), and 65 for further investigations of abnormal findings from the screening (screened). The ratio of prevalent to incident (= clinical + screened) cases, which is related to the duration of clinical phase, was the highest in hypertensive, thyroid, ophthalmologic disorders. This indicates that health services for prevalent cases of those diseases are needed in addition to primary and secondary preventive efforts. The proportion of screened cases in the incident cases, which reflects the ability of the screening program to detect diseases in the preclinical phase, was the highest for anemia, disorders of lipid metabolism, and hypertensive disorders. The smaller proportions in dermatologic, urologic and orthopedic disorders indicate that preventive methods for these disorders should be considered in the future. In conclusion, monitoring of screening participants by prospective follow-up and analysis by two measures proposed in this study seem promising for continuing evaluation of the effectiveness of an on-going screening program. A network system of hospitals and physicians' offices should be developed, by which the information on the visits to outpatient clinics after screening is collected and analyzed periodically for monitoring.     

Improving cancer control through a community-based cancer awareness initiative

ObjectiveTo assess the impact of the Cancer Research UK Cancer Awareness Roadshow on intentions to change health behaviours and use local health services related to cancer.MethodFeedback forms from visitors to three Roadshows collected data on anticipated lifestyle changes and health service use following their visit to the Roadshow. Demographic predictors of intentions were investigated.ResultsA total of 6009 individuals completed a feedback form. On average, respondents intended to make between two and three (2.55; SD = 1.77) lifestyle changes, and use between none and one (0.59; SD = 0.77) local health services following their visit. Multivariable analysis showed that age (p = 0.001), ethnicity (p = 0.006), and occupation (p = 0.043) were significant predictors of anticipated lifestyle changes. Anticipated health service use was higher among men (p = 0.001), younger groups (p < 0.001), and smokers (p < 0.001). Overall effects of ethnicity (p = 0.001) and occupation (p < 0.001) on anticipated health service use were also observed. Post-hoc analyses indicated stronger effects of the Roadshow among disadvantaged groups.ConclusionHigh levels of anticipated health behaviour change and health service use were observed among Roadshow visitors. Disadvantaged groups such as lower socioeconomic groups, ethnic minorities, and smokers showed particularly high levels of intention. A more in-depth evaluation of the Roadshow is warranted.     

Improving health and energy efficiency through community-based housing interventions

Objectives  

Houses designed for one climate and cultural group may not be appropriate for other places and people. Our aim is to find cost-effective ways to improve the characteristics of older homes, ill-fitted for New Zealand’s climate, in order to improve the occupants’ health.     

Neighborhood design and walking. A quasi-experimental longitudinal study

BACKGROUND: Few studies have employed longitudinal data to examine associations between the physical environment and walking. METHODS: Using cross-sectional (n=70) and longitudinal (n=32) data (collected 2003-2006), associations of neighborhood design and demographics with walking were examined. Participants were low-income, primarily African-American women in the southeastern U.S. Through a natural experiment, some women relocated to neo-traditional communities (experimental group) and others moved to conventional suburban neighborhoods (control group). RESULTS: Post-move cross-sectional comparisons indicated that women in neo-traditional neighborhoods did not, on average, walk more than women in suburban neighborhoods. Race and household size were significant predictors of physical activity. Additionally, using longitudinal data, this study controlled for the effects of pre-move walking and demographics. Analyses examined the effects of environmental factors (e.g., density, land-use mix, street-network patterns) on post-move walking. Women who moved to places with fewer culs-de-sac, on average, walked more. Unexpectedly, increases in land-use mix were associated with less walking. CONCLUSIONS: Results suggest that neo-traditional neighborhood features alone (e.g., sidewalks, front porches, small set-back distances) may not be enough to affect walking; however, changes in street patterns may play a role.     

A community-based approach to influenza assessment and treatment during a pandemic

In the event of an influenza pandemic, hospitals and community-based health services will be overwhelmed. To ensure that life-saving health services are able to continue, the Ontario Health Plan for an Influenza Pandemic (OHPIP) provides direction for assessing and treating patients with influenza, remotely and through the implementation of alternate assessment, treatment and referral centres (Flu Centres). The OHPIP also provides tools and resources for local pandemic planners to assist them with the implementation of this strategy.     

Creating community-based access to primary healthcare for the uninsured through strategic alliances and restructuring local health department programs.

In 2003, the Wilkes County Health Department joined with county healthcare providers to develop the HealthCare Connection, a coordinated and continuous system of low-cost quality care for uninsured and low-income working poor. Through this program, local providers of primary and specialty care donate specialty care or ancillary services not provided by the Health Department, which provides case management for the program. Basing their methods on business models learned through the UNC Management Academy for Public Health, planners investigated the best practices for extending healthcare coverage to the underinsured and uninsured, analyzed operational costs, discovered underutilized local resources, and built capacity within the organization. The HealthCare Connection is an example of how a rural community can join together in a common business practice to improve healthcare access for uninsured and/or low-income adults.     

Improving public health through access to and utilization of medication assisted treatment

Providing access to and utilization of medication assisted treatment (MAT) for the treatment of opioid abuse and dependence provides an important opportunity to improve public health. Access to health services comprising MAT in the community is fundamental to achieve broad service coverage. The type and placement of the health services comprising MAT and integration with primary medical care including human immunodeficiency virus (HIV) prevention, care and treatment services are optimal for addressing both substance abuse and co-occurring infectious diseases. As an HIV prevention intervention, integrated (same medical record for HIV services and MAT services) MAT with HIV prevention, care and treatment programs provides the best "one stop shopping" approach for health service utilization. Alternatively, MAT, medical and HIV services can be separately managed but co-located to allow convenient utilization of primary care, MAT and HIV services. A third approach is coordinated care and treatment, where primary care, MAT and HIV services are provided at distinct locations and case managers, peer facilitators, or others promote direct service utilization at the various locations. Developing a continuum of care for patients with opioid dependence throughout the stages MAT enhances the public health and Recovery from opioid dependence. As a stigmatized and medical disenfranchised population with multiple medical, psychological and social needs, people who inject drugs and are opioid dependent have difficulty accessing services and navigating medical systems of coordinated care. MAT programs that offer comprehensive services and medical care options can best contribute to improving the health of these individuals thereby enhancing the health of the community.     

A study on effectiveness of screening mammograms

BACKGROUND: So far, no randomized controlled trials with a mean mammographic screening interval of > or = 2 years has demonstrated statistically significant mortality reduction for women younger than age 50. The issue of screening frequency is vital in detection of primary breast cancer. METHODS: The study group consisted of cancers diagnosed in women who participated in a serial screening programme with a mean screening interval of 2 years. To study the effectiveness of the screening, a comparison is made between the distribution of age at which the tumour could be detected when biennial mammographic screening is the only detection method, and the distribution of age at which the tumour would be detected by either biennial mammographic screening or the development of symptoms. Some recently developed statistic methods, such as bootstrap, the maximum likelihood distribution estimator for doubly censored data and the EM algorithm, are used in estimation of these distributions. RESULTS: The hypothesis tests and confidence intervals show that the difference between the two distributions was statistically significant for women younger than 50 and 50-70 years old, but not for women over 70 years. CONCLUSIONS: The statistical analysis indicates that for women younger than 50, and 50-70 years of age, a screening mammogram every other year is not frequent enough to detect primary breast cancer, but for women over 70 years, it might be sufficient.     

Improving access to specialty care

BACKGROUND: Waits and delays plague health care systems worldwide, and wait times for most specialists exceed those for primary care practices. In office-based practices, the provider office presence is not diluted by competing indispensable activities, and the demand for service is most often for a single type, or stream, of office-based appointment demand. In the more complex specialty practices, however, the demand streams for office visits and other services compete for provider time and dilute the supply of office visits. SEVEN FLOW STRATEGIES, WITH A FOCUS ON THE INITIAL APPOINTMENT: Seven strategies for reduction of delay can be applied, not only at all steps in patient flow and for all demand streams but also at all steps (for example, office visit, diagnostic procedure, surgery, follow-up) and within all specialty care types and ranges of practice. Each specialty care practice will need to discover how to use the basic principles and implement customized solutions within its own unique environment. Although it is ultimately critical to eliminate the delays in all streams of service, the focus is on the application of change strategies at the initial step between primary care and all specialty care practice types. The strategies are (1) balance supply and demand at each step in the chain, (2) work down the backlog, (3) reduce appointment types, (4) independent contingency planning for all variation, (5) reduce the demand for visits, (6) increase the supply, and (7) improve the efficiency of the office work flow. SUMMARY: Specialists support various, distinct demand streams that require demand/supply balance to achieve optimal system performance. If demand/supply balance exists within any stream, waits can be minimized, and the practice can choose time frames within which to balance workload.     

Bringing care to the community: expanding access to health care in rural Malawi through mobile health clinics

Setting: Malawi has chronic shortages of health workers, high burdens of human immunodeficiency virus (HIV) infection and malaria and a predominately rural population. Mobile health clinics (MHCs) could provide primary health care for adults and children in hard-to-reach areas.Objectives: To determine the feasibility, volume, and types of services provided by three MHCs from 2011 to 2013 in Mulanje District, Malawi.Design: Cross-sectional retrospective study.Results: The MHCs conducted 309 492 visits for primary health care, and in 2013 services operated on 99% of planned days. Despite an improvement in service provision, overall patient visits declined over the study period. Malaria and respiratory and gastro-intestinal conditions constituted 60% of visits. Females (n = 11 543) significantly outnumbered males (n = 2481) tested for HIV, yet males tested HIV-positive (27%) more often than females (14%). Malaria accounted for 26 421 (35%) visits for children aged <5 years, with a significant increase in the rainy season. Implementation of rapid diagnostic testing was associated with a decline in numbers treated for malaria. Antibiotic stockouts at government clinics were associated with increased MHC visits.Conclusion: MHCs can routinely provide primary health care for adults and children living in rural Malawi and complement fixed clinics. Moving from a complementary role to integration within the government health system remains a challenge.     

Estimating influenza vaccine efficacy from challenge and community-based study data

In this paper, the authors provide estimates of 4 measures of vaccine efficacy for live, attenuated and inactivated influenza vaccine based on secondary analysis of 5 experimental influenza challenge studies in seronegative adults and community-based vaccine trials. The 4 vaccine efficacy measures are for susceptibility (VE(S)), symptomatic illness given infection (VE(P)), infection and illness (VE(SP)), and infectiousness (VE(I)). The authors also propose a combined (VE(C)) measure of the reduction in transmission in the entire population based on all of the above efficacy measures. Live influenza vaccine and inactivated vaccine provided similar protection against laboratory-confirmed infection (for live vaccine: VE(S) = 41%, 95% confidence interval (CI): 15, 66; for inactivated vaccine: VE(S) = 43%, 95% CI: 8, 79). Live vaccine had a higher efficacy for illness given infection (VE(P) = 67%, 95% CI: 24, 100) than inactivated vaccine (VE(P) = 29%, 95% CI: -19, 76), although the difference was not statistically significant. VE(SP) for the live vaccine was higher than for the inactivated vaccine. VE(I) estimates were particularly low for these influenza vaccines. VE(SP) and VE(C) can remain high for both vaccines, even when VE(I) is relatively low, as long as the other 2 measures of vaccine efficacy are relatively high.     

Improving access to clinical offices

Optimal access to office care requires a detailed understanding of a practice's capacity to provide care and demand for services. Once capacity and demand are known, they can be effectively managed to provide care today for those needs that arise today. Such a system of "open access" benefits clinicians and patients alike. This article describes specific steps a practice can take to achieve open access.     

Improving access to health care in Latino communities.

Public debate about health care reform often focuses on the need for health insurance coverage, but in Latino communities many other barriers also inhibit access to medical care. In addition, basic public health services often go underfunded or ignored. Thus, health care reform efforts, nationally and in each State, must embrace a broader view of the issues if the needs of Latino communities are to be served. This report reviews and summarizes information about the mounting problems Latino communities face in gaining access to medical care. Access to appropriate medical care is reduced by numerous financial, structural, and institutional barriers. Financial barriers include the lack of health insurance coverage and low family incomes common in Latino communities. More than 7 million Latinos (39 percent) go without health insurance coverage. Latinos without health insurance receive about half as much medical care as those who are insured. Structurally, the delivery system organization rarely reflects the cultural or social concerns of the communities where they are located. Therefore, providers and patients fail to communicate their concerns adequately. These communication problems are exacerbated by the extreme shortage of Latino health care professionals and other resources available. Institutional barriers often reflect the failure to consider what it means to provide good service as well as high-quality medical care. Reducing these barriers to medical care requires modifying governmental and institutional policies, expanding the supply of competent providers, restructuring delivery system incentives to ensure primary care and public health services, and enhancing service and satisfaction with care.     

Managing access to primary care clinics using scheduling templates

Health Care Management Science - An important challenge confronting healthcare is the effective management of access to primary care. Appointment scheduling policies/templates can help strike an...