Social inequalities in the demand for dental care

BACKGROUND: Despite excellent general health indices, Quebec is in a difficult situation concerning oral health: tooth loss remains at a high level in adults and reveals important social inequalities. The objective of this research was to show that dental health inequalities reflect inequalities in the demand for dental care. METHODS: For the Dental Health Survey of Quebec 1998-1999, 9930 parents of children aged 5 to 8 years were randomly selected across Quebec and received a questionnaire at their home on the demand for dental care. Among them, 8430 adults completed and sent back the questionnaire (responses rate: 85%). After excluding edentulous persons, the sample was reduced to 6585 parents aged 30 to 44 years. RESULTS: The majority of respondents (76.4% of women and 72.8% of men) visit the dentist in a preventive manner rather than wait until dental problems occur. However, our study shows important disparities: the proportion of preventive attenders increases as income increases. A multiple logistic regression model suggests that there are financial as well as cultural barriers in dental care access. CONCLUSION: The proportion of preventive attenders is high in Quebec and allows practitioners to adopt a preventive management of dental caries. Social disparities are high however, and are associated with financial as well as cultural barriers that need to be reduced.     

Palliative care at the end of life: comparing quality in diverse settings

There is growing awareness that pain and other symptoms are often poorly managed at the end of life. The purpose of this quality improvement project was to compare the quality of care provided to a convenience sample of 195 patients who died during a six-month period, using a retrospective chart review. Quality was defined by symptom documentation, use of diagnostic and therapeutic procedures in the final 48 hours of life, and determination of advance directives. Daily and total charges incurred by these patients were also captured. Symptom distress was common, and diagnostic and therapeutic procedures were widespread. These data suggest areas for improvement in clinical practice, in palliative care units, and in all settings where end-of-life care is provided. Also, the data can guide future research into the quality of care provided to dying persons.     

Pathology reports provided reliable and readily accessible records of surgical procedures performed in women with breast cancer

OBJECTIVE: Extracting complete and accurate records of surgical procedures from case-notes is time consuming and laborious. We compared the completeness and time taken to extract data on surgical procedures from case-notes and from pathology reports. STUDY DESIGN AND SETTING: Information on surgical procedures was extracted from pathology reports and hospital case-notes for 111 women with breast cancer in three centers. The time taken to perform this task was recorded. Surgical procedures were classified into diagnostic and therapeutic procedures, and analysis was performed to determine the completeness and accuracy of the documentation of the procedures. RESULTS: The average time taken to extract relevant information from the pathology reports (3.0 minutes) was one-fifth that for the case-notes (14.4 minutes). The case-notes documented slightly fewer procedures than the pathology records: 94 vs. 108 diagnostic and 108 vs. 110 therapeutic procedures, respectively. Of the 219 therapeutic and diagnostic surgical procedures recorded by both data sources, for 216 procedures there was exact agreement as to the specific type of procedure performed. CONCLUSIONS: Extraction of information on surgical procedures is faster from pathology records than from case-notes. The level of agreement for the specific type of procedure performed is excellent and, if anything, the pathology records are more complete than the case-notes.     

Sedation by non-anesthesiologists should be centralized for considerations of safety]

Sedation and analgesia for diagnostic or therapeutic procedures outside the operating room by non-anaesthesiologist physicians is becoming more frequent. In reaction to sedation casualties a multidisciplinary committee organized by the National Organization for Quality Assurance in Hospitals (CBO) has developed guidelines for sedation and analgesia by non-anaesthesiologists for psychologically or physically distressing diagnostic and therapeutic procedures. In these guidelines the conditions for a qualitatively safe way of sedation or analgesia are being emphasized. It may be expected that with these guidelines sedation and analgesia by non-anaesthesiologists will increase further. With a view to the safety of the patient diagnostic and therapeutic procedures which require sedation for psychological or physical reasons should be concentrated in a diagnostic/therapeutic complex, connected to the operating complex, where it is possible to consult the expertise of an anaesthesiologist.     

Cost-effectiveness of drug-eluting coronary stents in Quebec, Canada

OBJECTIVES: The aim of this investigation was to assess the incremental cost-effectiveness of replacing bare metal coronary stents (BMS) with drug-eluting stents (DES) in the Province of Quebec, Canada. METHODS: The strategy used was a cost-effectiveness analysis from the perspective of the health-care provider, in the province of Quebec, Canada (population 7.5 million). The main outcome measure was the cost per avoided revascularization intervention. RESULTS: Based on the annual Quebec rate of 14,000 angioplasties with an average of 1.7 stents per procedure and a purchase cost of $2,600 Canadian dollar (CDN) for DES, 100 percent substitution of BMS with DES would require an additional $45.1 million CDN of funding. After the benefits of reduced repeat revascularization interventions are included, the incremental cost would be $35.2 million CDN. The cost per avoided revascularization intervention (18 percent coronary artery bypass graft, 82 percent percutaneous coronary intervention [PCI]) would be $23,067 CDN. If DES were offered selectively to higher risk populations, for example, a 20 percent subgroup with a relative restenosis risk of 2.5 times the current bare metal rate, the incremental cost of the program would be $4.9 million CDN at a cost of $7,800 per avoided revascularization procedure. Break-even costs for the program would occur at DES purchase cost of $1,161 for 100 percent DES use and $1,627 for selective 20 percent DES use for high-risk patients for restenosis (RR = 2.5). Univariate and Monte Carlo sensitivity analyses indicate that the parameters most affecting the analysis are the capacity to select patients at high risk of restenosis, the average number of stents used per PCI, baseline restenosis rates for BMS, the effectiveness ratio of restenosis prevention for DES versus BMS, the cost of DES, and the revascularization rate after initial PCI. Sensitivity analyses suggest little additional health benefits but escalating cost-effectiveness ratios once a DES penetration of 40 percent has been attained. CONCLUSIONS: Under current conditions in Quebec, Canada, selective use of DES in high-risk patients is the most acceptable strategy in terms of cost-effectiveness. Results of such an analysis would be expected to be similar in other countries with key model parameters similar to those used in this model. This model provides an example of how to evaluate the cost-effectiveness of selective use of a new technology in high-risk patients.     

Affording to wait: Medicare initiation and the use of health care

Delays in receipt of necessary diagnostic and therapeutic medical procedures related to the timing of Medicare initiation at age 65 years have potentially broad welfare implications. We use 2005-2007 data from Florida and North Carolina to estimate the effect of initiation of Medicare benefits on healthcare utilization across procedures that differ in urgency and coverage. In particular, we study trends in the use of elective procedures covered by Medicare to treat conditions that vary in symptoms; these are compared with elective surgical procedures not eligible for Medicare reimbursement, and to a set of urgent and emergent procedures. We find large discontinuities in health services utilization at age 65 years concentrated among low-urgency, Medicare-reimbursable procedures, most pronounced among screening interventions and treatments for minimally symptomatic disease.     

Occupational radiation doses to operators performing cardiac catheterization procedures

Cardiac catheterization procedures using fluoroscopy reduce patient morbidity and mortality compared to operative procedures. These diagnostic and therapeutic procedures require radiation exposure to patients and physicians. The objectives of the present investigation were to provide a systematic comprehensive summary of the reported radiation doses received by operators due to diagnostic or interventional fluoroscopically-guided procedures, to identify the primary factors influencing operator radiation dose, and to evaluate whether there have been temporal changes in the radiation doses received by operators performing these procedures. Using PubMed, we identified all English-language journal articles and other published data reporting radiation exposures to operators from diagnostic or interventional fluoroscopically-guided cardiovascular procedures from the early 1970's through the present. We abstracted the reported radiation doses, dose measurement methods, fluoroscopy system used, operational features, radiation protection features, and other relevant data. We calculated effective doses to operators in each study to facilitate comparisons. The effective doses ranged from 0.02-38.0 microSv for DC (diagnostic catheterizations), 0.17-31.2 microSv for PCI (percutaneous coronary interventions), 0.24-9.6 microSv for ablations, and 0.29-17.4 microSv for pacemaker or intracardiac defibrillator implantations. The ratios of doses between various anatomic sites and the thyroid, measured over protective shields, were 0.9 +/- 1.0 for the eye, 1.0 +/- 1.5 for the trunk, and 1.3 +/- 2.0 for the hand. Generally, radiation dose is higher on the left side of an operator's body, because the operator's left side is closer to the primary beam when standing at the patient's right side. Modest operator dose reductions over time were observed for DC and ablation, primarily due to reduction in patient doses due to decreased fluoroscopy/cineradiography time and dose rate by technology improvement. Doses were not reduced over time for PCI. The increased complexity of medical procedures appears to have offset dose reductions due to improvements in technology. The large variation in operator doses observed for the same type of procedure suggests that optimizing procedure protocols and implementing general use of the most effective types of protective devices and shields may reduce occupational radiation doses to operators. We had considerable difficulty in comparing reported dosimetry results because of significant differences in dosimetric methods used in each study and multiple factors influencing the actual doses received. Better standardization of dosimetric methods will facilitate future analyses aimed at determining how well medical radiation workers are being protected.     

Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries

This study analyzes administrative data from the Medicare program to compare differences by race in the use of 17 major procedures performed in the hospital. In both 1986 and 1992, black beneficiaries were less likely than white beneficiaries to have received these procedures while hospitalized. The largest differences were seen for "referral-sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. These differences by race suggest that there are barriers to these services. In contrast, black beneficiaries were found to have substantially higher rates than white beneficiaries in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which black beneficiaries have higher rates raise questions about whether there is a need for more comprehensive and continuous ambulatory care for the underlying health conditions associated with these procedures.     

Impact of the limited generalist (no hospital,no procedures) model on the viability of family practice training

BACKGROUND: Some doubt the desirability and cost-effectiveness of continuing to provide an expanded scope of primary care practice. Additionally, there has been concern about declining reimbursement from Medicaid and Medicare. Although an expanded scope of patient care services are required for training, we wanted to determine whether these services drain resources and time from other primary care activities. METHODS: To determine the financial impact of deleting services other than office visits from an urban primary care practice, we tabulated charges, economic case mix, and actual collections during 12 consecutive months. Using regional and national norms, the practice set charges for hospital services, office visits, and procedures at approximately 50th percentile as a maximum. Common diagnostic and therapeutic procedures were tabulated, and gross charges per item per year were tabulated. To validate net collection predictions for a predominately TennCare (Medicaid) practice and compare these with projected net collections from private practice, charges were compared with projected collections using two expectations (40% net and 80% net). Overall collections were projected and then compared with actual collection. For hospital services and office procedures, costs were attributed to equipment, training, liability insurance, and lost opportunity for office visits. The setting was an urban family practice teaching program providing hospital services, hospital deliveries, newborn care, office visits, and a variety of office procedures. There were 30,262 office visits, 510 non-pregnant hospitalizations, 252 deliveries, 1,352 office radiographs, and a variety of common office-based diagnostic and therapeutic procedures, such as electrocardiograms (408), skin surgeries (265), gastrointestinal endoscopies (306), diagnostic obstetric sonograms (525), non-stress tests (95), and colposcopy (161). The main outcome measures were the financial values calculated after subtracting costs for hospitalist services, office visits, and procedures. RESULTS: After lost opportunities for office visits are deducted, hospital services created positive revenue ranging from $167,306 to $340,612, depending on the net collection scenario chosen (ie, worst case versus best case). CONCLUSIONS: Revenue was adequate for reimbursement of equipment, staff, and physician time in either case. For procedural activities in the office, there was a net gain of $372,974 in charges once opportunities for lost office visits were deducted. Even within the 40% net collection scenario, revenue was more than adequate to pay for overhead and equipment. For this practice with 84% Medicaid-Medicare accounts, projected collections of 40% underestimated slightly the actual net revenue.     

Inequality in treatment use among elderly patients with acute myocardial infarction: USA, Belgium and Quebec

Background  

Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.     

Application of a diagnostic decision rule in children with meningeal signs: a cost-minimization study

OBJECTIVES: Recently, we developed a diagnostic rule for the diagnosis and treatment of children with meningeal signs. This rule may provide the physician with a rationale to decide on the use of diagnostic and treatment procedures in these children and to improve their care. In this study, we estimated cost savings of the rule compared with current practice. METHODS: Routine care data of 360 children visiting the emergency department of the Sophia Children's Hospital with meningeal signs between 1988 and 1998 were used. Costs of diagnostic tests and treatment were estimated by using financial accounts of an academic and a general pediatric hospital. The number of procedures actually performed and the resulting cost estimates (i.e. unit costs x volume) were compared with the estimated figures after application of the decision rule. RESULTS: The population of children with meningeal signs comprised 99 with bacterial meningitis (27%), 36 with another serious bacterial infection (10%), and 225 with a self-limiting disease (63%). Application of the rule would reduce lumbar punctures by 12% and hospitalizations for empirical treatment by 15% with the same diagnostic accuracy as current practice. Cost savings were estimated at Euro292 per patient (relative reduction 10%) and were mainly achieved in the treatment course (Euro259). CONCLUSIONS: A diagnostic decision rule for children with meningeal signs has the potential to improve the appropriate use of medical resources, to be cost-effective, and to ascertain the absence of bacterial meningitis earlier.     

Mayo Clinic employees responded to new requirements for cost sharing by reducing possibly unneeded health services use

Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20?percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.     

Chronic low back pain in primary care: a prospective study on the management and course

BACKGROUND: There is little evidence about the management and course of chronic low back pain in primary care. OBJECTIVES: Our aim was to describe the course of chronic low back pain and the performed diagnostic and therapeutic procedures for patients with chronic low back pain in general practice. METHODS: Twenty-six GPs involved in the Registration Network Family Practices participated in this prospective follow-up study. All patients and GPs were asked to complete questionnaires at baseline and at 4, 8 and 12 months follow-up. RESULTS: The GPs provided information about diagnostic and therapeutic procedures concerning 524 patients with chronic low back pain. Diagnostic tests other than history-taking and physical examination were not frequently used. Medication, mostly NSAIDs, was the most frequently used type of treatment (21.6%). The most frequent referrals concerned physiotherapy (16.3%) and neurology or neurologic surgery (6.3%). Information about the course of their chronic low back pain was provided by 368 patients participating in our study. The course of chronic low back pain appeared to be quite stable, as there was only a slight improvement in pain intensity and physical functioning over the 12 months of follow-up. CONCLUSIONS: A variety of options for the treatment and referral of chronic low back pain patients is available for and used by GPs. Efforts should be made to establish which diagnostic and therapeutic procedures are the most effective for chronic low back pain.      

Incidentally discovered adrenal masses

The result of the more wide spread use of abdominal imaging procedures has lead to reveal more incidentally discovered adrenal masses. In this review we evaluated the different biological an radiologic procedures to explore such tumors. We finally, presented a proposal of diagnostic and therapeutic algorithm for patients with incidental adrenal mass.     

Methods and consequences of pre-natal diagnostics

Prenatal medicine is a young subdiscipline of modern obstetrics. It applies diagnostic methods like amniocentesis, chorionic villus sampling and foetal blood sampling. The latter is not only a diagnostic procedure but opens access to the foetal circulation and therefore to foetal therapy. Aim of prenatal diagnostic procedures is the most exact diagnosis of the foetal condition as basis for rational obstetrical decisions. If a foetal disease is diagnosed, decisions are in principal similar to the postnatal situation, but therapeutic options are reduced. Decision making in prenatal medicine always has to take maternal and foetal interests into account. We have to consider that not the methods but the intention and actions of the persons involved may cause an ethical dilemma. It must be our aim to use the methods of prenatal medicine with the utmost responsibility.     

Health decentralization in the state of Mato Grosso, Brazil: financing and care model]

This piece analyzes the funding of the public Unified Health System (UHS) in the state of Mato Grosso, Brazil, in order to identify the model of care that has been taking shape there since 1994. We studied 16 municipalities, selected according to their size, degree of involvement with the UHS, and socioeconomic and health conditions. We found that between 1994 and 1998 there were large increases in health spending, due to higher municipal expenditures and to rising intergovernmental transfers for outpatient care. However, the health care system taking shape in a large number of Mato Grosso municipalities is increasingly focused on an individual, curative, specialized, and highly technological type of care. Indicative of this trend is the fact that the biggest increases in spending for outpatient care--up to 300% in some municipalities--have come from diagnostic and therapeutic procedures that are of medium or high complexity. Since the resources for health care are limited, and since the model of care adopted by many municipalities continues to shift resources from primary health care to more complex procedures, we believe that the financial viability of the Unified Health System is coming into question. Although this study was limited to the state of Mato Grosso, other Brazilian municipalities are no doubt facing similar situations. The same is probably true for municipalities in other South American countries that have adopted decentralization of the health care system as one of the strategies for State reform.     

Canadian federalism and the Canadian health care program: a comparison of Ontario and Quebec

The Quebec and Ontario health insurance and health service delivery systems, developed within the parameters of federal regulations and national financial subsidies, provide generally universal and comprehensive basic hospital and medical benefits and increasingly provide for the delivery of long-term care services. Within a framework of cooperative federalism, the health care systems of Ontario and Quebec have developed uniquely. In terms of vital statistics, the health of Ontario and Quebec residents generally is comparable. In viewing expenditures, Quebec has a more clearly articulated plan for providing accessible services to low-income persons and for integrating health and social services, although it has faced some difficulties in seeking to achieve the latter goal. Its plans for decentralized services are counter-balanced by a strong provincial role in health policy decision-making. Quebec's political culture also allows the province to play a stronger role in hospital planning and in the regulation of physician income than one finds in Ontario. These political dynamics allow Quebec an advantage in control of costs. In Ontario, in spite of some recent setbacks, physician interests and hospital sector interests play a more active role in health system bargaining and are usually able to influence remuneration and resource allocation decisions more than physician interests and hospital sector interests in Quebec.     

Regional differences in appropriateness of cholecystectomy in a prepaid health insurance system.

BACKGROUND: Previous studies have reported variation in the population-based use rate of diagnostic and therapeutic procedures. Cholecystectomy is one of the most common surgical procedures, and we conducted this study to assess whether in Israel the use of this procedure varied by region and whether differences in use can be related to differences in appropriateness of use. In Israel, there is a pre-paid health insurance system and all surgeons are salaried. METHODS: Age-adjusted rates of cholecystectomy in four hospitals, each serving a defined population in Israel, were calculated. Two hundred and sixty-six potential clinical indications for performing cholecystectomy were rated as to their appropriateness by a panel of 9 expert physicians. A trained team abstracted the medical records of all patients who underwent the operation in the four Israeli hospitals in 1986 (n = 702) and recorded the clinical indication for the surgery. RESULTS: The population-based age-adjusted rates of cholecystectomy varied over threefold among the four hospitals. 29% of the cholecystectomies were performed for less than appropriate reasons, and this figure varied by hospital from 36% to 17% (p = 0.002). However, appropriateness did not vary systematically with the population-based use rate. CONCLUSION: Cholecystectomy was performed frequently for inappropriate or equivocal reasons, even in a country in which resources are limited, and physicians are salaried. Efforts to improve surgical decision making should be undertaken.     

Three unusual cases of mastocytosis]

A unique opportunity arose to introduce the rare disease called mastocytosis as we had three patients with radically different clinical signs and disease progression. The authors would like to draw attention to the diagnostic problems that may emerge with this disease, as well as the diagnostic procedures are detailed. These problems, however, are dwarfed by the therapeutic difficulties faced by the clinicians. Complete remission with the present treatment opportunities may not be achieved, nevertheless, there are options to improve quality of life and to alleviate the symptoms that cause suffering to patients.