BMC Health Services Research - Latest Articles

Health care utilisation amongst Shenzhen migrant workers: does being insured make a difference?

Jin Mou — 2009-11-21T00:00:00Z

Background: As one of the most populous metropolitan areas in the Pearl River Delta of South China, Shenzhen attracts millions of migrant workers annually. The objectives of this study were to compare health needs, self-reported health and healthcare utilisation of insured and uninsured migrant workers in Shenzhen, China, where a new health insurance scheme targeting at migrant workers was initiated. Methods: A cross-sectional survey using multi-staged sampling was conducted to collect data from migrant factory workers. Statistical tests including logistic regression analysis were used. Results: Among 4634 subjects (96.54%) who responded to the survey, 55.11% were uninsured. Disease patterns were similar irrespective of insurance status. The uninsured were more likely to be female, single, younger and less educated unskilled labourers with a lower monthly income compared with the insured. Out of 1136 who reported illness in the previous two weeks, 62.15% did not visit a doctor. Of the 296 who were referred for inpatient care, 48.65% did not attend because of inability to pay. Amongst those who reported sickness, 548 were insured and 588 were uninsured.Those that were insured, and had easier access to care were more likely to make doctor visits than those who were uninsured. Conclusions: Health care utilisation patterns differ between insured and uninsured workers and insurance status appears to be a significant factor. The health insurance system is inequitably distributed amongst migrant workers. Younger less educated women who are paid less are more likely to be uninsured and therefore to pay out of pocket for their care. For greater equity this group need to be included in the insurance schemes as they develop.

Predicting intention to treat HIV-infected patients among Tanzanian and Sudanese medical and dental students using the theory of planned behaviour-a cross sectional study

Anne Astrom — 2009-11-20T00:00:00Z

Background: The HIV epidemic poses significant challenges to the low income countries in sub Saharan Africa (SSA), affecting the attrition rate among health care workers, their level of motivation, and absenteeism from work. Little is known about how to deal with deterioration of human resources in the health care systems. This study aimed to predict the intention to provide surgical treatment to HIV infected patients among medical- and dental students in Tanzania and Sudan using an extended version of the Theory of Planned Behaviour (TPB). Methods: Four hundred and seventy five medical- and dental students at the University of Dar es Salaam ( mean age, 25 yr) and 642 dental students attending 6 public and private dental faculties in Khartoum ( mean age 21.7yr) completed self-administered TPB questionnaires in 2005 and 2007, respectively. Results: Both Tanzanian and Sudanese students demonstrated strong intentions to provide care for people with HIV and AIDS. Stepwise linear regression revealed that the TPB accounted for 51% (43% in Tanzania and Sudan) of the variance in intention across study sites. After having controlled for country and past behaviour, the TPB in terms of attitudes, subjective norms and perceived behavioural control accounted for 34% and moral norms for an additional 2,3% of the explainable variance in intention. Across both study sites, attitudes were the strongest predictor of intention followed in descending order by subjective norms, moral norms and perceived behavioural control. Conclusion: The TPB is applicable to students' care delivery intentions in the context of HIV and AIDS across the two SSA countries investigated. It is suggested that attitudes, subjective norms, moral norms and perceived behavioural control are key factors in students' willingness to treat AIDS and HIV infected patients and should be targets of interventions aimed at promoting quality health care delivery in this context.

The politics of local hospital reform: a case study of hospital reorganization following the 2002 Norwegian hospital reform

Trond Tjerbo — 2009-11-20T00:00:00Z

Background: The Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives.The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector.MethodThe empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies. Results: The analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo. Conclusion: Because of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arm's length may simply be unrealistic and further complicate the politics of local hospital reforms.

Cost analysis of the Dutch Obstetric system: low-risk nulliparous women preferring home or short-stay hospital birth - a prospective non-randomised controlled study

Marijke Hendrix — 2009-11-19T00:00:00Z

Background: In the Netherlands, pregnant women without medical complications can decide where they want to give birth, at home or in a short-stay hospital setting with a midwife. However, a decrease in the home birth rate during the last decennium may have raised the societal costs of giving birth. The objective of this study is to compare the societal costs of home births with those of births in a short-stay hospital setting. Methods: This study is a cost analysis based on the findings of a multicenter prospective non-randomised study comparing two groups of nulliparous women with different preferences for where to give birth, at home or in a short-stay hospital setting. Data were collected using cost diaries, questionnaires and birth registration forms. Analysis of the data is divided into a base case analysis and a sensitivity analysis. Results: In the group of home births, the total societal costs associated with giving birth at home were E3,695 (per birth), compared with E3,950 per birth in the group for short-stay hospital births. Statistically significant differences between both groups were found regarding the following cost categories 'Cost of contacts with health care professionals during delivery' (E138.38 vs. E87.94, -50 (2.5-97.5 percentile range (PR)-76;-25), p<0.05), 'cost of maternity care at home' (E1,551.69 vs. E1,240.69, -311 (PR -485; -150), p<0.05) and 'cost of hospitalisation mother' (E707.77 vs. E959.06, 251 (PR 69;433), p<0.05). The highest costs are for hospitalisation (41% of all costs). Because there is a relatively high amount of (partly) missing data, a sensitivity analysis was performed, in which all missing data were included in the analysis by means of general mean substitution. In the sensitivity analysis, the total costs associated with home birth are E4,364 per birth, and E4,541 per birth for short-stay hospital births. Conclusion: The total costs associated with pregnancy, delivery, and postpartum care are comparable for home birth and short-stay hospital birth. The most important differences in costs between the home birth group and the short-stay hospital birth group are associated with maternity care assistance, hospitalisation, and travelling costs.

Register data for cross-country comparisons of migrants' healthcare utilization in the EU: a survey study of availability and content

Signe Smith Nielsen — 2009-11-18T00:00:00Z

Background: Cross-national comparable data on migrants' use of healthcare services are important to address problems in access to healthcare; to identify high risk groups for prevention efforts; and to evaluate healthcare systems comparatively. Some of the main obstacles limiting analyses of health care utilization are lack of sufficient coverage and availability of reliable and valid healthcare data which includes information allowing for identification of migrants. The objective of this paper was to reveal which register data on healthcare utilization were available in the EU countries in which migrants can be identified; and to determine to what extent data were comparable between the EU countries. Methods: A questionnaire survey on availability of healthcare utilization registers in which migrants can be identified was carried out among all national statistic agencies and other relevant national health authorities in the 27 EU countries in 2008-9 as part of the Migrant and Ethnic Minority Health Observatory-project (MEHO). The information received was compared with information from a general survey on availability of survey and register data on migrants conducted by Agency of Public Health, Lazio Region, Italy within the MEHO-project; thus, the information on registers was double-checked to assure accuracy and verification. Results: Available register data on healthcare utilization which allow for identification on migrants on a national/regional basis were only reported in 11 EU countries: Austria, Belgium, Denmark, Finland, Greece, Italy, Luxembourg, the Netherlands, Poland, Slovenia, and Sweden. Data on hospital care, including surgical procedures, were most frequently available whereas only few countries had data on care outside the hospital. Regarding identification of migrants, five countries reported having information on both citizenship and country of birth, one reported availability of information on country of birth, and five countries reported availability of information on citizenship. Conclusions: Lack of register data in 16 EU countries, shortage of data on healthcare utilization, and the diversity in the definition of migrant status hampers cross-national comparisons and calls for an urgent establishment of registers, expansion of the existing register information, and adoption of a common, generally acceptable definition and identification method of migrants across EU.

Pharmaceutical cost control in primary care: opinion and contributions by healthcare professionals

Alexandra Prados-Torres — 2009-11-18T00:00:00Z

Background: Strategies adopted by health administrations and directed towards drug cost control in primary care (PC) can, according to earlier studies, generate tension between health administrators and healthcare professionals. This study collects and analyzes the opinions of general practitioners (GPs) regarding current cost control measures as well as their proposals for improving the effectiveness of these measures. Methods: A qualitative exploratory study was carried out using 11 focus groups composed of GPs from the Spanish regions of Aragon, Catalonia and the Balearic Islands. A semi-structured guide was applied in obtaining the GPs' opinions. The transcripts of the dialogues were analyzed by two investigators who independently considered categorical and thematic content. The results were supervised by other members of the team, with overall responsibility assigned to the team leader. Results: GPs are conscious of their public responsibility with respect to pharmaceutical cost, but highlight the need to spread responsibility for cost control among the different actors of the health system. They insist on implementing measures to improve the quality of prescriptions, avoiding mere quantitative evaluations of prescription costs. They also suggest moving towards the self-management of the pharmaceutical budget by each health centre itself, as a means to design personalized incentives to improve their outcomes. These proposals need to be considered by the health administration in order to pre-empt the feelings of injustice, impotence, frustration and lack of motivation that currently exist among GPs as a result of the implemented measures. Conclusions: Future investigations should be oriented toward strategies that involve GPs in the planning and management of drug cost control mechanisms. The proposals in this study may be considered by the health administration as a means to move toward the rational use of drugs while avoiding concerns about injustice and feelings of impotence on the part of the GPs, which can lead to lack of interest in and disaffection with the current measures.

Shelter-based convalescence for homeless adults in Amsterdam: a descriptive study

Igor van Laere — 2009-11-18T00:00:00Z

Background: Adequate support for homeless populations includes shelter and care to recuperate from illness and/or injury. This is a descriptive analysis of diagnoses and use of shelter-based convalescence in a cohort of homeless adults in Amsterdam. Methods: Demographics of ill homeless adults, diagnoses, referral pattern, length of stay, discharge locations, and mortality, were collected by treating physicians during outreach care provision in a shelter-based convalescence care facility in Amsterdam, from January 2001 through October 2007. Results: 629 individuals accounted for 889 admissions to the convalescence care facility. 83% were male and 53% were born in the Netherlands. The mean age was 45 years (SD 10 years). The primary physical problems were skin disorders (37%), respiratory disorders (33%), digestive disorders (24%) and musculoskeletal disorders (21%). Common chronic conditions included addictions 78%, mental health disorders 20%, HIV/AIDS 11% and liver cirrhosis 5%. Referral sources were self-referred (18%), general hospitals (21%) and drug clinics (27%). The median length of stay was 20 days. After (self)discharge, 63% went back to the previous circumstances, 10% obtained housing, and 23% went to a medical or nursing setting. By March 2008, one in seven users (n=83; 13%) were known to have died, the Standard Mortality Ratio was 7.5 (95% CI: 4.1-13.5). Over the years, fewer men were admitted, with significantly more self neglect, personality disorders and cocaine use. Lengths of stay increased significantly during the study period. Conclusion: Over the last years, the shelter-based convalescence care facility users were mainly homeless single males, around 45 years of age, with chronic problems due to substance use, mental health disorders and a frail physical condition, many of whom died a premature death. The facility has been flexible and responsive to the needs of the users and services available.

Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population

Vincent Chung — 2009-11-17T00:00:00Z

Background: In 1997 Hong Kong reunified with China and the development of traditional Chinese medicine (TCM) started with this change in national identity. However, the two latest discussion papers on Hong Kong's healthcare reform have failed to mention the role of TCM in primary healthcare, despite TCM's public popularity and its potential in tackling the chronic non-communicable disease (NCD) challenge in the ageing population. This study aims to describe the interrelationship between age, non-communicable disease (NCD) status, and the choice of TCM and western medicine (WM) services in the Hong Kong population. Methods: This study is a secondary analysis of the Thematic Household Survey (THS) 2005 dataset. The THS is a Hong Kong population representative face to face survey was conducted by the Hong Kong Administrative Region Government of China. A random sample of respondents aged >15 years were invited to report their use of TCM and WM in the past year, together with other health and demographic information. A total of 33,263 persons were interviewed (response rate 79.2%). Results: Amongst those who received outpatient services in the past year (n = 18,087), 80.23% only visited WM doctors, 3.17% consulted TCM practitioners solely, and 16.60% used both type of services (double consulters). Compared to those who only consulted WM doctor, multinomial logistic regression showed that double consulters were more likely to be older, female, NCD patients, and have higher socioeconomic backgrounds. Further analysis showed that the association between age and double consulting was curvilinear (inverted U shaped) regardless of NCD status. Middle aged (45-60 years) NCD patients, and the NCD free "young old" group (60-75 years) were most likely to double consult. On the other hand, the relationship between age and use of TCM as an alternative to WM was linear regardless of NCD status. The NCD free segment of the population was more inclined to use TCM alone as they become older. Conclusion: In Hong Kong, most patients have chosen WM provided in the public sector as their sole outpatient service provider for NCD. Amongst TCM service users, middle aged NCD patients are more likely to choose both TCM and WM outpatient services. Meanwhile, older people without NCD are more likely to use TCM as their main form of care, but the size of this population group is small. These utilization patterns show that patients choose both modalities to manage their NCD and TCM should be considered within policies for supporting patients with NCD under the wider primary health and social care system that supports patient choice.

Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system

David Ganz — 2009-11-16T00:00:00Z

Background: Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development. Methods: We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement. Results: The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it. Conclusion: A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.

Geriatric patients' expectations of their physicians: findings from a tertiary care hospital in Pakistan

Taimur Saleem — 2009-11-13T00:00:00Z

Background: Geriatric health is a neglected and under-explored area internationally and in Pakistan. We aimed to ascertain the expectations of the geriatric patients from their physicians and the factors associated with patient satisfaction in this particular age bracket. Methods: A cross-sectional survey was carried out at a tertiary care teaching hospital in Karachi, Pakistan. Data collection was carried out via face-to-face interviews based on structured, pre-tested questionnaires. All consenting individuals aged 65 years or above were recruited into the study. Convenience sampling was used to draw the sample. The data was analyzed using SPSS version 16. Geriatric patient's expectations from physicians were elicited using a set of 11 questions that were graded on a scale of 1-3 where 1 = not important, 2 = important, 3 = very important. Results: Three hundred and eighty geriatric patients were interviewed. The response rate of this study was 89.8%. The mean age of the respondents was 73.4 ± 6.8 years. Two hundred and forty eight respondents (65.3%) were female. Diabetes mellitus (53.7%), hypertension (59.5%), arthritis (40.5%) and renal disease (32.1%) were common ailments among geriatric patients. More than 50% of the patients were visiting their physicians once every two to three months. Discussing treatment options and letting patients make the final decision (79.2%), prescribing minimum possible medications (84.5%), physician's holistic knowledge about the spectrum of care issues for geriatric patients (79.2%), being given a realistic but optimistic picture of future health by physicians (85.5%) were ranked as very important expectations by patients from their physicians. Cumulative household income (p = 0.005), most important health complaint (p = 0.01) and frequency of experiencing health complaint (p < 0.001) emerged as independent predictors of the satisfaction of geriatric patients from care provided by physicians. Conclusion: We have documented the expectations of the geriatric patients from their physicians in a developing country. Physicians belonging to all disciplines should keep these expectations in mind during clinical encounters with geriatric patients.