Using the ecology model to describe the impact of asthma on patterns of health care

Ecology of End-of-life Medical Care for Advanced Cancer Patients in China

AIMS

Cancer is a leading cause of death worldwide. Approximately 30% of global cancer-related deaths occur in mainland China. However, there is a paucity of information regarding the end-of-life care-seeking behavior of patients with advanced cancer in China. Our study was to investigate end-of-life care-seeking behavior and to quantify the association between sociodemographic characteristics and the location and pattern of end-of-life care.

METHODS

We conducted a mortality follow-back survey using caregivers' interviews to estimate the number of individuals pre 1000 who died between 2013 and 2021 in the last 3 months of life. We collected data on hospitalization, outpatient visits, cardiopulmonary resuscitation, palliative care and hospice utilization, and place of death, stratified by age, gender, marital status, household income, residential zone, insurance type, and the primary end-of-life decision-maker of the decedents.

RESULTS

We analyzed data from 857 deceased cancer patients, representing an average of 1000 individuals. Among these patients, 861 experienced at least moderate or more severe pain, 774 were hospitalized at least once, 468 received intensive treatment, 389 had at least one outpatient visit, 270 died in the hospital, 236 received cardiopulmonary resuscitation and 99 received specialist hospice care.

CONCLUSIONS

Our study provides insights into the end-of-life care-seeking behavior of advanced cancer patients in China and our findings serve as a useful benchmark for estimating the use of end-of-life medical care. It highlights the need for the establishment of an accessible and patient-centered palliative care and hospice system.

The ecology of medical care in Shanghai

Background

To better understand the distribution and consumption patterns of resources in different ethnic groups and at different levels of economic development, this paper chose to describe the healthcare seeking behavior in Shanghai.

Methods

The data are from the Sixth Health Service Survey of Shanghai, which encompasses 23,198 permanent residents. Descriptive analyses were conducted to estimate the number of patients who reported health-related symptoms and healthcare-seeking behaviors per 1,000 residents. Logistic regression analyses were conducted to examine differences in reporting health-related symptoms and healthcare-seeking behaviors by age, gender and area of residence.

Results

This paper have mapped the ecology of healthcare in Shanghai in 2018. Of 1000 individuals considered during a 1-month period, 444 reported sickness, 433 received treatment, 288 went to medical institutions, 195 went to primary medical institutions, 86 took a self-healing approach, 26 received TCM services, 7 were hospitalized, and 3 underwent surgery.

Conclusions

Age is a risk factor leading to disease, medical treatment, self-medication, medical institution visits, TCM service, hospitalization and surgery. But age is a protective factor in the use of primary health care services. By gender, the number of people receiving medical services was similar, but women were statistically more likely to have surgery. As the income level increased, the number of patients and people receiving medical services showed a decreasing trend. Compared with the local population, the probability of non-local people visiting medical institutions was lower and statistically significant. Compared with the people who had health insurance, fewer uninsured people reported sickness and utilized healthcare services.

The Ecology of Medical Care in Korea

This study aimed to describe the ecology of medical care in Korea. Using the yearly data of 2012 derived from the Korea Health Panel, we estimated the numbers of people per 1,000 residents aged 18 and over who had any health problem and/or any medical care at a variety of care settings, such as clinics, hospitals, and tertiary hospitals, in an average month. There was a total of 11,518 persons in the study population. While the number of those who had any health problem in an average month was estimated to be 939 per 1,000 persons, the estimated numbers of ambulatory care users were 333 at clinics, 101 at hospital outpatient departments, 35 at tertiary hospital outpatient departments, and 38 for Korean Oriental medical providers. The number of people who used emergency care at least once was 7 per 1,000 persons in an average month. The numbers of people hospitalized in clinics and hospitals were 3 and 8, respectively, while 3 persons were admitted to tertiary hospitals. There was a gap between the number of people experiencing any health problem and that of those having any medical care, and primary care comprised a large share of people's medical care experiences. It was noteworthy that more patients received ambulatory care at tertiary hospitals in Korea than in other countries. We hope that discussion about care delivery system reform and further studies will be encouraged.

The ecology of health care in a Belgian area

INTRODUCTION

Focusing on the monthly prevalence of health problems and recourse to different levels of care of the population is an interesting approach to demonstrate the respective roles of different levels of health care. In the present study, the ecology of health care was studied in the region of Liège, Belgium.

METHOD

A survey questioning people about their health problems was conducted in 2009 in two communes of the province of Liège. For each health problem, 'health care' was defined as contact with any qualified care provider. For each consultation, three elements were recorded: the profession of the health care provider; the place where the care was provided and the kind of health care received.

RESULTS

A total of 537 people were interviewed. The monthly prevalence of people who experienced a health problem during the previous month was 85.1%. The monthly prevalence of people who turned to a health care provider at least once during the month was 62.2%. The proportion of people turning to doctors, primarily local doctors, for a simple consultation was important (49.2%).

DISCUSSION

Our results are highly comparable with those of other studies. Recourse to a doctor is high (49%), which probably reflects the broad accessibility of health care in Belgium and maybe its overuse. Additional questions on the current and future organisation of the Belgian health care system are debated.

The ecology of gynecological care for women

Gynecological care is vital to women’s health but utilization of gynecological care has been seldom addressed. We applied the population-based “ecology model” to demonstrate the utilization of gynecological care of women, with examples from Taiwan. We analyzed the claims data from the cohort datasets within the National Health Insurance Research Database in Taiwan. Women’s utilization of gynecological care in 2009 was computed. Of 1000 women, 319 utilized gynecological care at least once, 277 visited Western medicine clinics, 193 visited physician clinics, 118 visited hospital-based outpatient clinics, 73 visited traditional Chinese medicine clinics, eight were hospitalized, four were hospitalized in an academic medical center, and four visited emergency departments. More than 90% of young and middle-aged women who sought gynecological care visited gynecologist clinics. Elderly women were less likely to utilize gynecological care in all settings of medical care, but were more likely to be attended by non-gynecologists. Young women tended to visit emergency departments. The ecology model highlighted age disparities in women’s utilization of gynecological care in various settings of medical care. Since gynecological conditions were common among women, more attention should be paid on the availability of gynecologists and continuing medical education in gynecological care for non-gynecologists to guarantee women’s health.

Protocol for the asthma tools study: a pragmatic practice-based research network trial

Background

Asthma is common among children, adolescents, and adults. However, management of asthma often fails to follow evidence-based guidelines. Control assessments have been developed, validated against expert opinion, and disseminated. However, in primary care, assessment of control is only one step in asthma management. To facilitate integration of the evidence-based guidelines into practice, tools should also guide the next steps in care. The Asthma APGAR tools do just that, incorporating a control assessment as well as assessment of the most common reasons for inadequate and poor control. The Asthma APGAR tool is also linked to a care algorithm based on the 2007 National Heart, Lung, and Blood Institute asthma guidelines. The objective of this study is to assess the impact of implementation of the Asthma APGAR on patient asthma outcomes in primary care practices.

Methods

A total of 1400 patients aged 5–60 years with physician-diagnosed asthma are enrolled in 20 practice-based research network (PBRN) practices randomized to intervention or usual care. The primary outcomes are changes in patient self-reported asthma control, asthma-related quality of life, and rates of exacerbations documented in medical records over the 18–24 months of enrollment. Process measures related to implementation of the Asthma APGAR system into daily care will also be assessed using review of medical records. Qualitative assessments will be used to explore barriers to and facilitators for integrating the Asthma APGAR tools into daily practice in primary care.

Discussion

Data from this pivotal pragmatic study are intended to demonstrate the importance of linking assessment of asthma and management tools to improve asthma-related patient outcomes. The study is an effectiveness trial done in real-world PBRN practices using patient-oriented outcome measures, making it generalizable to the largest possible group of asthma care providers and primary care clinics.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Factors affecting health care utilization for children in Japan

BACKGROUND AND OBJECTIVE

Studies on the ecology of medical care for children have been reported only from the United States. Our objective was to describe proportions of children receiving care in 6 types of health care utilization seeking behaviors in Japan on a monthly basis and to identify care characteristics.

METHODS

A population-weighted random sample from a nationally representative panel of households was used to estimate the number of health-related symptoms, over-the-counter medicine doses, and health care utilizations per 1000 Japanese children per month. Variations in terms of age, gender, socioeconomic status, and residence location were also examined.

RESULTS

Based on 1286 households (3477 persons including 1024 children) surveyed, on average per 1000 children, 872 had at least 1 symptom, 335 visited a physician's office, 82 a hospital-based outpatient clinic, 21 a hospital emergency department, and 2 a university-based outpatient clinic. Two were hospitalized, and 4 received professional health care in their home. Children had 2 times more physician visits and 3 times more emergency visits than adults in Japan, and Japanese children had 2.5 times more physician visits and 11 times more hospital-based outpatient clinic visits than US children. Pediatric health care utilization is influenced significantly by age but not affected by income or residence location in Japan.

CONCLUSIONS

Compared with the data from the United States, more children in Japan visit community physicians and hospital-based outpatient clinics. Results of this study would be useful for further delineation of health care utilization of children in the context of a health care system unique to Japan.

Ecology of medical care in a publicly funded health care system: a registry study in Sweden

OBJECTIVE

To explore the influence of sociodemographic factors on access to appointments with physicians in primary, secondary, and tertiary health care in a publicly funded health care system.

DESIGN

A population-based registry study.

SETTING

Different health care settings in Västernorrland county, Sweden.

SUBJECTS

All residents in the county at the end of 2006.

MAIN OUTCOME MEASURES

The number of people per 1000 residents who had at least one appointment with a physician in an average month in different health care settings.

RESULTS

A total of 87 people had appointments with a physician in primary health care, 44 in outpatient clinics at a regional hospital, 20 in an emergency department, 14 in home care, and two in a university hospital outpatient clinic. Twelve were hospitalized at a regional hospital and <1 at the university hospital. Being young or elderly, female, divorced, widowed, and having a contractor as usual source of care were all independently associated with higher odds of receiving primary care.

CONCLUSIONS

The physician's office in primary care is the setting that has the potential to affect the largest number of people. The extent of the use of health care was independently influenced by all sociodemographic characteristics studied, which highlights the importance of individual factors in future resource allocation. Regarding availability the ecology model provides superior information as compared with the absolute number of physicians' appointments. The prerequisites in Sweden of high-quality registries and unique personal identification numbers encourage future research on the ecology model to optimize accessibility of health care.

Impact of delay in asthma diagnosis on health care service use

Delays in diagnosing asthma in children are common and are known to delay asthma-specific treatment. Few studies have investigated whether a delay in asthma diagnosis impacts the use of health care services. This study was designed to assess whether a delay in diagnosis of asthma influences the use of health care services. This was a retrospective cohort study with subjects elicited from a convenience sample of 839 healthy children. The criteria for asthma was met in 276 (33%) subjects; of these subjects 179 (65%) had a delay in the diagnosis of asthma and 97 (35%) had a timely diagnosis. Data on health care services (e.g., flu shot, availability of a peak flow meter, hospitalizations, and urgent care or emergency department visits) and the frequency of systemic steroid treatments were collected from medical records during the first 18 years of life. The frequencies of health service and use of systemic steroids were compared using Poisson and logistic regression models in asthmatic children with and without a delay in asthma diagnosis. Children with a delay in asthma diagnosis were more likely to visit urgent care centers at least once (40.8% versus 21.6%; p < 0.001), compared with those with a timely diagnosis. There were no significant differences in other health care service or systemic steroid use. A delay in the diagnosis of asthma was associated with an increase in urgent care visits suggesting suboptimal care. Clinicians should be aware that a delay in the diagnosis of asthma in children may result in the use of suboptimal health care services.

Spirometry can be done in family physicians' offices and alters clinical decisions in management of asthma and COPD

BACKGROUND

Spirometry is recommended for diagnosis and management of obstructive lung disease. While many patients with asthma and COPD are cared for by primary care practices, limited data are available on the use and results associated with spirometry in primary care.

OBJECT

To assess the technical adequacy, accuracy of interpretation, and impact of office spirometry.

DESIGN

A before-and-after quasiexperimental design.

SETTING

Three hundred eighty-two patients from 12 family medicine practices across the United States.

PARTICIPANTS

Patients with asthma and COPD, and staff from the 12 practices.

MEASUREMENTS

Technical adequacy of spirometry results, concordance between family physician and pulmonary expert interpretations of spirometry test results, and changes in asthma and COPD management following spirometry testing.

RESULTS

Of the 368 tests completed over the 6 months, 71% were technically adequate for interpretation. Family physician and pulmonary expert interpretations were concordant in 76% of completed tests. Spirometry was followed by changes in management in 48% of subjects with completed tests, including 107 medication changes (>85% concordant with guideline recommendations) and 102 nonpharmacologic changes. Concordance between family physician and expert interpretations of spirometry results was higher in those patients with asthma compared to those with COPD.

DISCUSSION AND CONCLUSIONS

US family physicians can perform and interpret spirometry for asthma and COPD patients at rates comparable to those published in the literature for international primary care studies, and the spirometry results modify care.

Resource utilization in asthma: combined fluticasone propionate/salmeterol compared with inhaled corticosteroids

BACKGROUND

Asthma management guidelines recommend low-dose inhaled corticosteroids (ICS) for initial treatment of mild persistent asthma. Instead, data from primary care practice show that many patients start on combination therapy with fluticasone propionate/salmeterol (FPS) for mild asthma. The consequences of this variance from guideline recommendations are not well described.

OBJECTIVE

Compare healthcare utilization and asthma-related outcomes for patients with mild asthma who began treatment with FPS or ICS alone. Design and data source: A retrospective analysis of asthma-related insurance claims. Patients initially treated with FPS or ICS were identified from an administrative health insurance claims database and followed for 1 year. Analyses of resource utilization 6 months before therapy initiation identified patients with mild asthma. Propensity score matching managed between-group differences in clinical characteristics and controlled for selection bias.

OUTCOME MEASURES

Resource use was determined for asthma-related outpatient visits, emergency room services, hospitalizations, and medications.

RESULTS

Demographic characteristics and comorbidities were similar for each group (FPS, n = 1888; ICS, n = 1888). During the 12-month follow-up period, total asthma-related costs were significantly higher for FPS versus ICS (1206 vs. 804 dollars; p < 0.0001), owing primarily to significantly higher drug costs for FPS versus ICS (677 vs. 357 dollars; p < 0.0001). The percentage of patients experiencing an exacerbation (14.0% FPS, 13.5% ICS) and the average number of exacerbations in each group (0.175 FPS, 0.164 ICS) were similar.

CONCLUSIONS

Healthcare costs were found to be lower in patients receiving ICS than in those receiving FPS, with similar health outcomes in both groups. Study limitations included the use of claims data and a proxy definition of asthma severity, and potential confounding by unobserved factors.

Being uninsured: impact on children's healthcare and health

PURPOSE OF REVIEW

There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children.

RECENT FINDINGS

With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs.

SUMMARY

Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.