The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey

Maternal and Child Health Journal - The purpose of this health system’s study is to assess the availability of Emergency Obstetric Care (EmOC) services in birthing centres in Taplejung...     

Burden of Healthcare Utilization and Out-of-Pocket Costs Among Individuals with NCDs in an Indian Setting

Non communicable diseases (NCDs) are now the major cause of death and disability worldwide. It increasingly affects people from developing as well as developed countries. Over the coming decades the burden from NCDs is projected to rise particularly fast in the developing world. There is a lack of optimal data collection about the burden of risk factors related to NCDs especially in the developing countries. To assess the burden of healthcare utilization and out-of-pocket costs associated with NCDs in an Indian setting. A cross sectional study was performed to enroll a convenient sample of 166 participants aged 18 years and above from a tertiary hospital in Punjab, a Northern state of India. The data was gathered during the period of Feb 2010–April 2010. A mixed methods approach was used to assess the burden of diabetes, hypertension, high cholesterol, and their associated risk factors. Further we evaluated the burden of healthcare utilization and out-of-pocket costs associated with these conditions using self-reported assessments. Results showed the average age of the participants was 50 years, 63 % (n = 104) were females, 32 % (n = 53) had education less than high school and 20 % (n = 33) had no formal education. About 96 % of the study participants were living with a partner. Majority of the study participants were non-smokers and 17 % (n = 27) of them reported to have history of alcohol consumption. The majority of the participants had access to cell phones (94 %; n = 156) and about 40 % (n = 66) had computers at home. About 33 % (n = 55) of the study participants had some form of previous knowledge of computers. Majority of the study participants went to the private hospital (47.5 %) for seeking healthcare. About 32 % (n = 53) also sought healthcare from some kind of healthcare professional including a primary care doctor or a nurse or even a pharmacist in a village setting. Doctor visits related to diabetes were higher as compared to the individuals either with hypertension or high cholesterol. However; the out-of-pocket costs of the visit to the healthcare professional were much higher for hypertension than for diabetes or high cholesterol. A strengthened surveillance system, effective inter-sectoral action, and improved access to basic healthcare are pivotal to prevent NCDs. A multifaceted NCDs surveillance system could help us measure the burden of risk factors, its associated health care utilization and out of pocket costs, and further facilitate interventions that can guide evidence based decision making.     

农村新型合作医疗制度与传统合作医疗的比较

农村合作医疗制度是一种以互助共济为基础,依靠集体经济和群众集资举办的以解决农民基本医疗保健问题为目的的医疗保健制度.80年代初,世界银行和世界卫生组织都曾派专家组来我国考察农村卫生.考察组的报告特别强调指出,"中国农村实行的合作医疗制度是发展中国家群体解决卫生经费的唯一范例".世界卫生组织还在另一份考察报告中诧"初级卫生工作人员的提出主要来自中国的启发.中国在占80%人口的农村地区发展了一'个成功的基层卫生保健系统,向人民提供低费用和适宜的医疗保健技术服务,满足大多数人的基本卫生需求,这种模式很适合发展中国家的需要."     

Commentary on Obstetric Care in Rural Georgia

This is an invited commentary on five articles on obstetric care in rural Georgia.     

Malpractice Burden, Rural Location, and Discontinuation of Obstetric Care: A Study of Obstetric Providers in Michigan

ABSTRACT:  Context: It has long been a concern that professional liability problems disproportionately affect the delivery of obstetrical services to women living in rural areas. Michigan, a state with a large number of rural communities, is considered to be at risk for a medical liability crisis. Purpose : This study examined whether higher malpractice burden on obstetric providers was associated with an increased likelihood of discontinuing obstetric care and whether there were rural-urban differences in the relationship. Methods : Data on 500 obstetrician-gynecologists and family physicians who had provided obstetric care at some point in their career (either currently or previously) were obtained from a statewide survey in Michigan. Statistical tests and multivariate regression analyses were performed to examine the interrelationship among malpractice burden, rural location, and discontinuation of obstetric care. Findings : After adjusting for other factors that might influence a physician's decision about whether to stop obstetric care, our results showed no significant impact of malpractice burden on physicians' likelihood to discontinue obstetric care. Rural-urban location of the practice did not modify the nature of this relationship. However, family physicians in rural Michigan had a nearly 4-fold higher likelihood of withdrawing obstetric care when compared with urban family physicians. Conclusions : The higher likelihood of rural family physicians to discontinue obstetric care should be carefully weighed in future interventions to preserve obstetric care supply. More research is needed to better understand the practice environment of rural family physicians and the reasons for their withdrawal from obstetric care.     

乡镇从事包皮环切人员的基线调查

目的了解乡镇从事包皮环切人员的基本情况、日常工作情况、专业技术水平及存在的问题,为确定最佳的管理方式提供依据。方法本研究对新疆天山南部塔里木盆地北部、相互毗连的库车县、新和县、沙雅县所有乡镇的所有从事包皮环切人员进行入户问卷调查。结果乡镇从事包皮环切人员共88人,均为男性,维吾尔族,年龄在24～71岁,平均年龄为44.00±11.75岁;初中及以下文化程度者占42!5%,最高学历是本科;在所有研究对象中,有11!4%的人是跟着父亲学的技术;当别人的徒弟而学的占30!6%;有34!1%的人带着徒弟施行包皮环切;非医务人员,包括传统包皮环切者、农民和其他职业的一般人员占23!9%,29!5%的人是既从事医疗又从事农业生产的村医。村医和祖传包皮环切者的收费时间、收费数额、收费方式非常灵活。研究对象当中,有71!6%的人员施行过集体包皮环切。在一次集体包皮环切当中,被包皮环切的人数最多达10人,平均3.69±1.71人。集体包皮环切的间隔时间最短1分钟,平均17.58±13.68分钟。结论艾滋病、乙型肝炎、丙型肝炎等血液传播疾病通过包皮环切传染的潜在危害比较大。应该加强对乡镇从事包皮环切人员的管理、监督,提高其素质,对其实行最佳的管理方式。     

Identification of Unmet Healthcare Needs: A National Survey in Thailand

Objectives:This study examined demographic factors hampering access to healthcare at hospitals and suggests policy approaches to improve healthcare management in Thailand.Methods:The data for the study were drawn from a health and welfare survey conducted by the National Statistical Office of Thailand in 2017. The population-based health and welfare survey was systematically carried out by skilled interviewers, who polled 21 519 384 individuals. The independent variables related to demographic data (age, sex, religion, marital status, education, occupation, and area of residence), chronic diseases, and health insurance coverage. The dependent variable was the degree of access to healthcare. Multiple logistic regression analysis was subsequently performed on the variables found to be significant in the univariate analysis. Results:Only 2.5% of the population did not visit a hospital when necessary for outpatient-department treatment, hospitalization, or the provision of oral care. The primary reasons people gave for not availing themselves of the services offered by government hospitals when they were ill were—in descending order of frequency—insufficient time to seek care, long hospital queues, travel inconvenience, a lack of hospital beds, unavailability of a dentist, not having someone to accompany them, and being unable to pay for the transportation costs. Multiple logistic regression analysis showed that failure to access the health services provided at hospitals was associated with demographic, educational, occupational, health welfare, and geographic factors. Conclusions:Accessibility depends not only on health and welfare benefit coverage, but also on socioeconomic factors and the degree of convenience associated with visiting a hospital.     

Healthcare Utilization After Stroke: A 1-Year Prospective Study

ObjectivesThis study was undertaken to investigate the predictive value of disease-related factors, contextual factors, and functioning on the use of healthcare for 1 year after stroke.DesignA prospective study.Setting and ParticipantsIn total, 219 patients with stroke admitted to a hospital stroke unit were included.MethodsData were obtained through medical records, structured interviews, and assessments. Multivariable regression analyses were used to explore the association between the independent variables (stroke severity, comorbidity, age, sex, civil status, private financing, sense of coherence, cognitive function, walking ability, social everyday activities prestroke, and recent fall) and the use of inpatient or outpatient care 0 to 3, 3 to 6 and 6 to 12 months after stroke.ResultsMean age of the participants was 70 years, 43% were women, and 71% experienced mild stroke severity. All participants received inpatient care at 0 to 3 months, about one-fifth used inpatient care at 3 to 6 or 6 to 12 months, and all received outpatient care all 3 time periods. Moderate-severe stroke (P < .001), a lower age (P = .002), and walking disability (P < .001) were associated with a higher use of inpatient care 0 to 3 months after stroke. Living alone (P = .025) and recent fall (P = .05) were associated with a higher use of inpatient care 3 to 6 months after stroke. None of the independent variables were associated with use of inpatient care 6 to 12 months. Moderate-severe stroke (0–3; 3–6 months: P < .001, 6–12 months: P = .004), a lower age (0–3 months: P = .002, 3–6 months: P = .001, 6–12 months: P = .006), and walking disability (P < .001) were associated with a higher use of outpatient care in all 3 time periods.Conclusions and ImplicationsModerate-severe stroke, lower age, and walking disability are important predictors of healthcare utilization after stroke. The findings inform efforts to identify and support people with stroke who have the potential for high healthcare utilization in the year post stroke.     

迎接农村区域医疗的新时代

近年以来,卫生部在全国范围内陆续展开了农村卫生信息化的试点项目,其中,首批试点项目在陕西子长和安塞县正式启动。卫生部表示,建设基层医疗卫生服务体系是新医改的五项重点工作之一,也是建设和谐社会中最受关注的民生工程,是政府解决看病难、     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

Quantifying Downstream Healthcare Utilization in Studies of Genomic Testing

ObjectivesThe challenges of understanding how interventions influence follow-up medical care are magnified during genomic testing because few patients have received it to date and because the scope of information it provides is complex and often unexpected. We tested a novel strategy for quantifying downstream healthcare utilization after genomic testing to more comprehensively and efficiently identify related services. We also evaluated the effectiveness of different methods for collecting these data.MethodsWe developed a risk-based approach for a trial of newborn genomic sequencing in which we defined primary conditions based on existing diagnoses and family histories of disease and defined secondary conditions based on unexpected findings. We then created patient-specific lists of services associated with managing primary and secondary conditions. Services were quantified based on medical record reviews, surveys, and telephone check-ins with parents.ResultsBy focusing on services that genomic testing would most likely influence in the short-term, we reduced the number of services in our analyses by more than 90% compared with analyses of all observed services. We also identified the same services that were ordered in response to unexpected findings as were identified during expert review and by confirming whether recommendations were completed. Data also showed that quantifying healthcare utilization with surveys and telephone check-ins alone would have missed the majority of attributable services.ConclusionsOur risk-based strategy provides an improved approach for assessing the short-term impact of genomic testing and other interventions on healthcare utilization while conforming as much as possible to existing best-practice recommendations.     

Patient-Centered Prenatal Counseling: Aligning Obstetric Healthcare Professionals With Needs of Pregnant Women

The first trimester aneuploidy screen (FTS) continues to be a leading approach to identify the risk of fetal aneuploidy. This study evaluated how obstetric (OB) professionals counsel women about FTS as one of a growing number of options to assess fetal health. A survey was completed by OB professionals (board-certified obstetrician/gynecologists and certified nurse midwives) between February and March 2011: (1) to identify knowledge and practice patterns with regard to FTS, and (2) to compare pregnant women’s educational needs and decision-making preferences with clinicians’ perceptions of these factors. A total of 216 surveys (11 percent) were completed by OB professionals and analyzed. Several barriers to effective patient counseling were identified, including gaps in obstetric professionals’ mastery of the screening test characteristics and variable approaches to discuss concepts of aneuploidy risk. OB participants reported limited confidence in discussing patient-valued topics, specifically post-screen options and pregnancy termination. Discordance was identified between OB professionals’ perceptions of pregnant women’s educational needs and decision-making preferences specific to FTS and historical data recently collected from 139 pregnant women who underwent the FTS. Study findings illustrate the need for clinician-targeted strategies to support pregnant women as they formulate informed decisions about the tests that may have a salient impact on their prenatal care decisions.     

苏州市儿童卫生服务利用状况调查

目的 了解苏州市儿童卫生服务利用情况,初步分析影响卫生服务利用的因素.方法 采用横断面调查的设计和随机抽样的方法,对1 800名儿童家长或监护人进行电话问卷调查.结果 调查对象过去一个月内发热、流涕和腹泻的发生率分别为7.0％、38.3％和4.0％.对不同症状的就诊行为分析,发热患儿的就诊比例最高,为83.9％;其次是有呕吐症状的患儿,就诊比例为46.9％.对就诊意向分析,若儿童出现发热、咳嗽/流涕、呕吐/腹泻等症状时,选择就诊的比例分别为96.4％、70.0％和92.0％.影响就诊行为的因素主要是家长选择自行服药治疗,影响就诊意向的主要原因是医院看病人太多.结论 苏州市儿童流感等常见症状的发生率较高,应诊行为和意向在市内三个城区存在差异.     

Customers' Precedence for Service Quality Dimensions in Indian Private Healthcare Setting: A Ridit Approach

Changes in demographic and sociocultural environment, improved health awareness, and information technology have considerably changed the outlook of healthcare sector in India. While both the public and the private healthcare sectors have priority of increasing access while minimizing costs, they try hard to achieve goals without letting the quality suffer. Customers with rising disposable income no longer have faith in the public healthcare system and are willing to migrate to the private healthcare sector, which is more professional, technology savvy, and trustworthy. However, there are enough loopholes in the private healthcare sector that are yet to be plugged. The purpose of this research study was to identify and assess the relative importance of the diverse service quality dimensions and prioritize them to draw meaningful conclusions. Survey responses from 370 customers were analyzed using factor analysis to find underlying relationships between the survey items. This allowed the individual items to be placed into related groups. Independently, a ridit analysis was conducted to determine the relative importance of each item to the survey respondents. Based on the ridit analysis a priority ranking was assigned to each item. An analysis was then undertaken of the degree to which the items grouped into each particular factor tended to have high or low priority rankings. The results of the study may be helpful to the managers of the private healthcare sector to focus their strategies and plan their efforts in line with the findings to gain superior customer satisfaction and retention.     

广州市城镇人口医药卫生服务可及性调查报告

采用分层随机抽样的方法对广州市常住人口医药卫生可及性进行了电话调查。目前,广州城镇人口大多数自付过医药费用,相当一部分城镇人口自付的医药费用比例过高,药品费用在城镇人口自付的医疗费用项目中居首位,城镇人口自付医药费用的主要原因是没有其他选择。城镇人口医疗保障覆盖面还不高,30%的城镇人口没有参加任何一种医疗保障项目。城镇人口在就医时倾向于选择大医院。完善基本医疗保障制度,引导患者就医行为,推进医药分家体制改革,转变基本医疗保障费用支付方式和加大公共卫生投入改革有助于提高广州市目前城镇人口医疗卫生服务可及性。     

新农合对卫生服务利用公平性影响的连续追踪调查

目的 通过基线与3次追踪调查的比较,研究新农合卫生服务利用公平性的动态变化,为完善新农合实施方案提供科学依据.方法 采用多阶段分层随机抽样抽取3个县9个乡27个行政村,每县约1 860户农民作为研究对象,连续4年入户调查,将4次调查结果进行纵向对比研究,运用集中指数(CI)、不平等斜率指数(SII)及利用/需要比进行公平性评价.结果 两周就诊率、因经济困难未就诊比例、需住院未住院率、因经济困难未住院比例均呈下降趋势,两周未就诊率、年住院率均呈上升趋势.除2008年的因经济困难未就诊比例、需住院未住院率的CI绝对值小于0.3外,其余各项指标均小于0.2;但两周未就诊率、因经济困难未就诊比例、需住院未住院率、因经济困难未住院比例的CI和SII绝对值均呈上升趋势.利用/需要比呈总体上升趋势,Spearman等级相关分析显示,4次调查利用/需要比均与经济收入无显著相关.结论 新农合实施以来,农民的卫生服务利用公平性总体状况良好,但经济状况较差农民的卫生服务利用公平性问题应引起重视.