Current and future worldwide prevalence of dependency, its relationship to total population, and dependency ratios

OBJECTIVE

To estimate the number of people worldwide requiring daily assistance from another person in carrying out health, domestic or personal tasks.

METHODS

Data from the Global Burden of Disease Study were used to calculate the prevalence of severe levels of disability, and consequently, to estimate dependency. Population projections were used to forecast changes over the next 50 years.

FINDINGS

The greatest burden of dependency currently falls in sub-Saharan Africa, where the "dependency ratio" (ratio of dependent people to the population of working age) is about 10%, compared with 7-8% elsewhere. Large increases in prevalence are predicted in sub-Saharan Africa, the Middle East, Asia and Latin America of up to 5-fold or 6-fold in some cases. These increases will occur in the context of generally increasing populations, and dependency ratios will increase modestly to about 10%. The dependency ratio will increase more in China (14%) and India (12%) than in other areas with large prevalence increases. Established market economies, especially Europe and Japan, will experience modest increases in the prevalence of dependency (30%), and in the dependency ratio (up to 10%). Former Socialist economies of Europe will have static or declining numbers of dependent people, but will have large increases in the dependency ratio (up to 13%).

CONCLUSION

Many countries will be greatly affected by the increasing number of dependent people and will need to identify the human and financial resources to support them. Much improved collection of data on disability and on the needs of caregivers is required. The prevention of disability and provision of support for caregivers needs greater priority.

Use of mental health services by men injured through community violence

OBJECTIVE

The aim of this study was to assess the use of mental health services and predictors of use among men injured through community violence.

METHODS

This one-year prospective study examined use of mental health services in a sample of 231 men who were injured through community violence and hospitalized at an urban trauma center. Predictors of mental health service use that were examined included age, ethnicity, income, neuroticism, injury severity, previous mental health service use, and need for services. Need for services was defined objectively by self-report of symptoms of posttraumatic stress disorder (PTSD) and subjectively by perception of an injury-related emotional problem.

RESULTS

Univariate logistic regression analysis showed that older age, non-Latino ethnicity, previous use of services, and need for services predicted service use in the year after the injury. In a multivariate logistic regression analysis, objective and subjective need for services and older age predicted postinjury service use. In the subset of men who were symptomatic postinjury, only older age and objective need predicted use of mental health services.

CONCLUSIONS

Despite high rates of need for services related to PTSD after violent injury in this sample, the rate of mental health service use was low. Psychoeducation about postinjury reactions and attention to structural barriers to services may help increase rates of care in this population.

ICTs application for better health in Nepal

Technologies with the ability to send information in a fast, efficient and cheap fashion--such as the Internet-can provide dramatic improvements in access to information, advice and care. This article explores the strengths and weaknesses of Internet to augment traditional health services and supply new ones. In doing so, it presents concrete cases in the developing world, with reference to Nepal, where Internet is being used for health-related activities--ranging from patient/doctor consultation through database services, to the management of epidemics.

Barriers to Treating Depression in the Family Physician's Office

This qualitative research aims to understand, from the standpoint of the family physician, the barriers to treating depression in the office setting. Three primary barriers to treating depression in the family physician's office were identified: systemic, physician-related, and patient-related. The systemic barriers involved the shortage of qualified, publicly-funded counsellors, lack of locally available counselling, and the cost of medication. Physician-related barriers included lack of time and expertise, and inadequacies of the reimbursement system. Patient-related barriers were rooted in the stigma attached to depression and failure to comply with treatment.

Access to care for children of migratory agricultural workers: factors associated with unmet need for medical care

OBJECTIVE

To assess the correlates of unmet need for medical care among migrant children.

DESIGN AND SETTING

A cross-sectional household survey used multistage sampling to identify migrant families in eastern North Carolina.

PARTICIPANTS

Three hundred adult caretakers of 1 (per household) randomly selected child <13 years old.

RESULTS

Fifty-three percent of the children had an unmet medical need. The most common reasons for unmet medical need were lack of transportation (80%) and lack of knowledge of where to go for care (20%). Unmet medical need was associated inversely with less than very good health (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.16-0.61) and less than high school caretaker education (OR: 0.62; 95% CI: 0.39-0.98) and was associated directly with 1) having bed-days due to illness (OR: 2.46; 95% CI: 1.42-4.26), 2) lacking an annual well examination (OR:1.89; 95% CI: 1.12-3.20), 3) transportation dependence (OR:1.97; 95% CI: 1.24-3.13), 4) female gender (OR: 1.69; 95% CI: 1.07-2.67), 5) preschool age (OR: 2.24; 95% CI: 1.28-3.92), and 6) very high caretaker work pressure (OR: 5.01; 95% CI: 2.98-8.42). Adjustment using multiple logistic regression reveals unmet medical need to be independently associated with preschool age (OR: 2.08; 95% CI: 1.05-4.13) and very high caretaker pressure to work (OR: 5.93; 95% CI: 3.24-10.85). Of sampled children, 27% were preschool aged, and 40% had caretakers categorized with high work pressure.

CONCLUSIONS

Medical-access barriers among migrant children are largely nonfinancial. Preschool-aged migrant children disproportionately experience unmet medical need. Decreasing forgone care among migrant children will likely require a combination of individual, health-system, and labor-policy modifications.

Cardiac procedures after an acute myocardial infarction across nine Canadian provinces

BACKGROUND

Geographical variations in the use of invasive cardiac procedures have been documented. It remains unclear to what extent these variations exist across the Canadian provinces.

OBJECTIVE

To describe variation in the use of invasive cardiac procedures and waiting times for these procedures across nine Canadian provinces.

METHODS

Using longitudinal, de-identified patient data from the Canadian Institute for Health Information, records of patients who had suffered an acute myocardial infarction (AMI) in each of nine Canadian provinces between 1997/1998 and 1999/2000 were selected. Rates and median waiting times for percutaneous coronary intervention and coronary artery bypass graft surgery were calculated by age, sex and health region.

RESULTS

There was a large variation in the use of and waiting times for invasive cardiac procedures across the Canadian provinces studied. In general, cardiac procedure rates in Western provinces were higher than in Eastern provinces, most notably higher than in the Maritime provinces and Ontario. In addition to interprovincial variation, there was also significant regional variation in the rates of revascularization and waiting times. Rates of percutaneous coronary intervention increased over the study period, whereas rates of bypass surgery remained relatively stable.

CONCLUSIONS

Significant variation in the use of cardiac procedures after AMI exists across Canada and this April represent potential inequalities in the treatment of AMI across Canada.

How much medical care do the uninsured use, and who pays for it?

With the number of uninsured people exceeding forty-one million in 2001, insuring the uninsured is again a major policy issue. This analysis establishes benchmarks for the inevitable debate over the cost of expanding coverage: How much is being spent on care for the uninsured, and where does the money come from? This information is essential for assessing how much new money will be required for expanded coverage, how much can be reallocated from existing sources, and how a new financing system would redistribute the burden of subsidizing care for the uninsured from private to public sources.

Does U.S. hospital capacity need to be expanded?

Some industry experts believe that U.S. hospital capacity--especially emergency and inpatient services--is being stretched to its limits. Using data from the Community Tracking Study, this paper examines constrained hospital services, contributing factors, and hospitals' responses. Most hospitals studied had emergency capacity problems, but problems in other service areas were limited to only a few hospitals. Hospitals have added or converted capacity, improved capacity management, dealt with nursing shortages, and worked with public officials to reduce emergency department diversions. Although additional capacity might be needed in some markets, better management of existing resources could be a more effective solution.

Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States

OBJECTIVE

To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness.

DESIGN

Retrospective cohort study based on claims data from the US Medicare programme.

PARTICIPANTS

Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report "best hospitals" list for heart and pulmonary disease, cancer, and geriatric services.

MAIN OUTCOME MEASURES

Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit.

RESULTS

Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrollment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%).

CONCLUSION

Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.

ASAM Patient Placement Criteria Treatment Levels

We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.

Barriers to access to mental health services for ethnic seniors: the Toronto study

OBJECTIVE

To identify and describe barriers to access to mental health services encountered by ethnoracial seniors.

METHOD

A multiracial, multicultural, and multidisciplinary team including a community workgroup worked in partnership with seniors, families, and service providers in urban Toronto Chinese and Tamil communities to develop a broad, stratified sample of participants and to guide the study. This participatory, action-research project used qualitative methodology based on grounded theory to generate areas of inquiry. Each of 17 focus groups applied the same semistructured format and sequence of inquiry.

RESULTS

Key barriers to adequate care include inadequate numbers of trained and acceptable mental health workers, especially psychiatrists; limited awareness of mental disorders among all participants: limited understanding and capacity to negotiate the current system because of systemic barriers and lack of information; disturbance of family support structures; decline in individual self-worth; reliance on ethnospecific social agencies that are not designed or funded for formal mental health care; lack of services that combine ethnoracial, geriatric, and psychiatric care; inadequacy and unacceptability of interpreter services; reluctance of seniors and families to acknowledge mental health problems for fear of rejection and stigma; lack of appropriate professional responses; and inappropriate referral patterns.

CONCLUSIONS

There is a clear need for more mental health workers from ethnic backgrounds, especially appropriately trained psychiatrists, and for upgrading the mental health service capacity of frontline agencies through training and core funding. Active community education programs are necessary to counter stigma and improve knowledge of mental disorders and available services. Mainstream services require acceptable and appropriate entry points. Mental health services need to be flexible enough to serve changing populations and to include services specific to ethnic groups, such as providing comprehensive care for seniors.

[337 home calls during daytime from the emergency medical center in Oslo]

BACKGROUND

Few studies have addressed physicians' home calls in Norway. The aim of this study is to analyse home calls during daytime in Oslo in relation to patients (age, sex, district), diagnoses, request procedures, and clinical outcome.

METHODS AND MATERIAL

General practitioners in the City of Oslo emergency medical centre recorded their home calls during three months using a standardised form.

RESULTS

Calls to 337 patients (mean age 70, median 77 years; two thirds females; seven to children below two years of age) were recorded. The home calls were requested by relatives (36%), the patients themselves (32%), community care nurses (11%), and nursing homes (7%). The assessments made by the operators of the medical emergency telephone were generally correct. Physicians reported 77% full and 20% partial match between reported and found medical problem. The physicians assessed that 22% of the patients would have been able to go and see a doctor. 39% of all patients were admitted to hospital, 34 % needed ambulance transportation. The admitting GPs received hospital reports only after 27% of admissions.

INTERPRETATION

Access to acute home calls by a physician during daytime is a necessary function in an urban public health service.

Utilization of care during pregnancy in rural Guatemala: does obstetrical need matter?

This study examines factors associated with the use of biomedical care during pregnancy in Guatemala, focusing on the extent to which complications in an ongoing or previous pregnancy affect a woman's decisions to seek care. The findings, based on multilevel models, suggest that obstetrical need, as well as demographic, social, and cultural factors, are important predictors of pregnancy care. In contrast, measures of availability and access to health services have modest effects. The results also suggest the importance of unobserved variables--such as quality of care--in explaining women's decisions about pregnancy care. These results imply that improving proximity to biomedical services is unlikely to have a dramatic impact on utilization in the absence of additional changes that improve the quality of care or reduce barriers to access. Moreover, current efforts aimed at incorporating midwives into the formal health-care system may need to extend their focus beyond the modification of midwife practices to consider the provision of culturally appropriate, high-quality services by traditional and biomedical providers alike.

General practitioners' educational needs in intellectual disability health

BACKGROUND

The community general practitioner (GP) has a central role in the provision of primary health care to people with intellectual disability (ID) as an indirect result of deinstitutionalization in Australia. This population, however, continues to experience poor health care compared to the general population. The current paper describes results from a questionnaire that aimed to identify the perceptions of practising GPs on the standards of health care for people with ID, the adequacy of prior training, and their interest in further education in relation to nine health care areas.

METHOD

A questionnaire was posted to a selective sample of 1272 practising GPs in Victoria selected from a database from the Centre for Developmental Disability Health Victoria and the Victorian Medical Directory of GPs registered with the Australian Medical Association. Data were available for 252 respondents with a response rate of 28.5%.

RESULTS

The health areas in which many GPs reported to be inadequately trained were the same as those areas that were perceived as being of a poor standard. These areas were behavioural or psychiatric conditions, human relations and sexuality issues, complex medical problems, and preventative and primary health care. Ninety four per cent of respondents were interested in further education in at least one of the nine health care areas, with the most frequently nominated areas being behavioural or psychiatric conditions, syndrome-specific medical problems, human relations and sexuality issues and collaboration with government services. General practitioners did not nominate complex medical problems or preventative and primary health care for further education as frequently as they identified care in these areas to be substandard and their prior training inadequate.

CONCLUSIONS

The findings from the current research are discussed in relation to the implications for development of educational programmes based on learning needs identified by the GP. The most frequently nominated health care areas in all three questions were behavioural or psychiatric conditions and human relations and sexuality issues. Reasons for incongruence between the frequency of responses for complex medical problems and preventative and primary health care are explored.

Correction of Refractive Error in the Adult Population of Bangladesh: Meeting the Unmet Need

PURPOSE

To assess the extent of uncorrected refractive error and associated factors in Bangladesh and to suggest ways in which this need can be met.

METHODS

A nationally representative sample of 12,782 adults (>/= 30 years of age) was selected. Of them, 11,624 subjects underwent a demographic interview, visual acuity (logarithm of the minimum angle of resolution [logMAR]) measurement, automated refraction, and optic disc examination. Subjects with visual acuity less than 6/12 in either eye also had a corrected refraction measurement, cataract grading, and dilated retinal examination.

RESULTS

Of the 11,624 subjects examined, 2,469 (22.1%) were myopes (less than -0.5 D) and 2,308 (20.6%) hyperopes (more than +0.5 D). The spectacle coverage percentage, calculated as [met need/(met need + unmet need) x 100%] was 25.2% and 40.5%, using 6/12 and 6/18 visual acuity cutoffs, respectively, and was higher in men and urban inhabitants. Older subjects and the literate and more highly educated were more likely to wear spectacles; however, most spectacle wearers (81%) had inadequate correction. Of the 1142 subjects who would benefit from spectacles, 827 (72.4%) would be suitable for off-the-shelf spectacles. Subjects without spectacles with less than 6/12 in the better eye (n = 835), would achieve 6/12 or better with correction (unmet need). Extrapolation to the national population yields an estimate that 1.5 million (6.7%) adult men and 1.8 million (9.2%) women have an unmet need for refractive correction.

CONCLUSIONS

In Bangladesh, there is low spectacle coverage with a large unmet need. This survey identified risk groups, in particular women and those living in rural areas. This description of the availability of refractive services suggests areas for improvement (e.g., off-the-shelf spectacles) that may enable Bangladesh to achieve the goals of the World Health Organization's Vision 2020 initiative.

The demand for evening ENT out-patient appointments

Increasing patient choice is a major theme of the NHS plan. For clinicians, this may mean offering NHS out-patient services at unfamiliar times, such as evenings or weekends. Published surveys of patients' views generally show high levels of satisfaction with appointments between 9 am and 5 pm, although there is a cohort of younger, employed patients who have expressed interest in evening clinics. This study attempted both to quantify the demand for evening ENT clinics and to target the patient group most likely to take up the offer of an evening appointment. When surveyed, approximately one-quarter of four hundred and fifty out-patients stated they would have preferred an evening appointment. However, when this group was targeted and formally offered a choice of time, only 1% of patients tried to change from daytime to evening. There is effectively no demand amongst NHS patients for ENT evening out-patient clinics.

Strategies to address increased demand for colonoscopy: Guidelines in an open endoscopy practice

BACKGROUND AND AIMS

Since Medicare approval for reimbursement of screening colonoscopies, the number of colonoscopy requests has increased. Physician resources have often been inadequate to meet the demand. We sought to reduce the demand for colonoscopy in an open endoscopy system by using a guideline-based triage system to eliminate inappropriate procedures and to align the timing of surveillance colonoscopies with recommendations made by national organizations.

METHODS

This was a cohort study with primary care outpatients. From October 2002 to February 2003, 498 consecutive patients on a waiting list of 2400 awaiting colonoscopy for all indications were triaged and are the focus of the study. Selection of patients for appropriate colonoscopy was based on consensus guidelines developed for institutional use by using established published guidelines for appropriate colonoscopy indications.

RESULTS

Of the 498 consecutive patients triaged, 139 (28%) were deemed inappropriate. The most common reason was inappropriate referral for surveillance of colorectal polyps. The percentage of inappropriate referrals by the 3 largest referring specialties (internal medicine, family medicine, and gastroenterology) combined was also 28% with no statistically significant differences between specialties.

CONCLUSIONS

Most referrals for colonoscopy in an open-access endoscopy system were appropriate, although about 1 in 4 were not. Use of triage and further education of physicians regarding colonoscopy may optimize colonoscopy utilization.

Waiting times for eye surgery at a Toronto teaching hospital

BACKGROUND

Waiting times for eye surgery in Ontario have increased dramatically in recent years. We performed a study to compare the waiting times, the amount of operating time and the number of cases performed for various eye surgical procedures in 1999, 2000 and 2001 at a major Toronto teaching hospital.

METHODS

For 3 months (May, June and July) of 1999, 2000 and 2001, eye surgeons at the hospital reported how long their patients had to wait for surgery and how many patients they had waiting for surgery. The number of operating hours for eye surgery and the number of eye surgery cases in fiscal years 1999-2000, 2000-01 and 2001-02 were collected from a hospital database. Surgical procedures that were captured were cataract extraction, corneal transplantation, trabeculectomy (including phacotrabeculectomy), vitreoretinal surgery and adult strabismus surgery.

RESULTS

All surgeons responded to the survey. Median waiting times increased for all types of eye surgery between 1999 and 2001. The median wait for cataract extraction increased by 92%, from 3.0 to 5.8 months. For corneal transplantation the median wait doubled, from 5.5 to 11.0 months. The median wait for trabeculectomy increased by 60%, from 2.5 to 4.0 months. The median wait for vitreoretinal surgery almost tripled (191%), from 1.2 to 3.4 months. For adult strabismus surgery the median wait increased by 56%, from 8.0 to 12.5 months. Operating time was cut by over 1000 hours (from 5481 to 4434) from 1999-2000 to 2000-01 and then again, by 255 hours, from 2000-01 to 2001-02. Despite this, the number of surgical procedures performed decreased only slightly over the study period, from 4292 to 4099.

INTERPRETATION

The waiting times for all eye operations increased substantially between 1999 and 2001 at this Toronto teaching hospital. In addition, for each type of surgery the median waiting time was longer than the Ontario median, by 13% (cataract surgery) to 191% (vitreoretinal surgery). The fact that the number of cases performed decreased only slightly despite a dramatic decrease in operating time indicates that there was an increase in efficiency. Possible ways to reduce the long waits include implementing prioritization programs, increasing operating time and moving cataract surgery out of the hospital to a day surgical centre.

Distribution of US anesthesia providers and services

This study describes the correlation between anesthesia providers by type (Certified Registered Nurse Anesthetist [CRNA] or anesthesiologist) and their respective rural or urban distributions across America. Analyses are based on county level data contained in several distinct databases with a given assumption that most providers practice and reside in the same rural or urban designation category. Data reveal that 91.6% (28,569) of active practicing anesthesiologists reside in metropolitan counties and that 8.4% (2,625) reside in nonmetropolitan counties. Of the 26,658 active practicing CRNAs, 81.4% (21,701), reside in metropolitan counties as opposed to 18.6% (4,957) in nonmetropolitan counties. Overall, analyses indicate that out of a total of 3,140 counties, there are 843 counties in the United States where neither anesthesiologists nor CRNAs reside. Ninety-seven percent (816) of these counties are nonmetropolitan.

Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center

BACKGROUND

Previous studies defining perioperative risk factors for allogeneic transfusion requirements in cardiac surgery were limited to highly selected cardiac surgery populations or were associated with high transfusion rates. The purpose of this study was to determine perioperative risk factors and create a formula to predict transfusion requirements for major cardiac surgical procedures in a center that practices a multimodality approach to blood conservation.

METHODS

We performed an observational study on 307 consecutive patients undergoing coronary artery bypass grafting, valve, and combined (coronary artery bypass grafting and valve) procedures. An equation was derived to estimate the risk of transfusion based on preoperative risk factors using multivariate analysis. In patients with a calculated probability of transfusion of at least 5%, intraoperative predictors of transfusion were identified by multivariate analysis.

RESULTS

Thirty-five patients (11%) required intraoperative or postoperative allogeneic transfusions. Preoperative factors as independent predictors for transfusions included red blood cell mass, type of operation, urgency of operation, number of diseased vessels, serum creatinine of at least 1.3 mg/dL, and preoperative prothrombin time. Intraoperative factors included cardiopulmonary bypass time, three or fewer bypass grafts, lesser volume of acute normovolemic hemodilution removed, and total crystalloid infusion of at least 2,500 mL. The derived formula was applied to a validation cohort of 246 patients, and the observed transfusion rates conformed well to the predicted risks.

CONCLUSIONS

A multimodality approach to blood conservation in cardiac surgery resulted in a low transfusion rate. Identifying patients' risks for transfusion should alter patient management perioperatively to decrease their transfusion rate and make more efficient use of blood resources.