BMC Health Services Research - Latest Articles
The latest research articles published by BMC Health Services Research

Support groups for dementia caregivers - Predictors for utilisation and expec...
by Elmar GraesselAngelika TrillingCarolin DonathKatharina Luttenberger
27 Jul 2010 at 6:00pm
Background: Support groups have proved to be effective in reducing the burden on family caregivers of dementia patients. Nevertheless, little is known about the factors that influence utilisation or quality expectations of family caregivers. These questions are addressed in the following paper. Methods: The cross-sectional study was carried out as an anonymous written survey of family caregivers of dementia patients in Germany. Qualitative and quantitative data from 404 caregivers were analysed using content analysis and binary logistic regression analysis. Results: The only significant predictor for utilisation is assessing how helpful support groups are for the individual care situation. Family caregivers all agree that psycho-educative orientation is a priority requirement. Conclusions: In order to increase the rate of utilisation, family caregivers must be convinced of the relevant advantages of using support groups. Support groups which offer an exchange of experiences, open discussion, information and advice meet the requirements of family caregivers.
Price regulation, new entry, and information shock on pharmaceutical market i...
by Fei-Yuan HsiaoYi-Wen TsaiWeng-Foung Huang
24 Jul 2010 at 6:00pm
Background: Using non-steroidal anti-inflammatory drugs (NSAIDs) as a case, we used Taiwan's National Health Insurance (NHI) database, to empirically explore the association between policy interventions (price regulation, new drug entry, and an information shock) and drug expenditures, utilization, and market structure between 2001 and 2004. Methods: All NSAIDs prescribed in ambulatory visits in the NHI system during our study period were included and aggregated quarterly. Segmented regression analysis for interrupted time series was used to examine the associations between two price regulations, two new drug entries (cyclooxygennase-2 inhibitors) and the rofecoxib safety signal and expenditures and utilization of all NSAIDs. Herfindahl index (HHI) was applied to further examine the association between these interventions and market structure of NSAIDs. Results: New entry was the only variable that was significantly correlated with changes of expenditures (positive change, p=0.02) and market structure of the NSAIDs market in the NHI system. The correlation between price regulation (first price regulation, p=0.62; second price regulation, p=0.26) and information shock (p=0.31) and drug expenditure were not statistically significant. There was no significant change in the prescribing volume of NSAIDs per rheumatoid arthritis (RA) or osteoarthritis (OA) ambulatory visit during the observational period. The market share of NSAIDs had also been largely substituted by these new drugs up to 50%, in a three-year period and resulted in a more concentrated market structure (HHI 0.17). Conclusions: Our empirical study found that new drug entry was the main driving force behind escalating drug spending, especially by altering the market share.
Socioeconomic inequalities in the use of outpatient services in Brazil accord...
by Celia SzwarcwaldPaulo SouzaGiseli Damacena
22 Jul 2010 at 6:00pm
Background: The Brazilian health system is founded on the principle of equity, meaning provision of equal care for equal needs. However, little is known about the impact of health policies in narrowing socioeconomic health inequalities. Using data from the Brazilian World Health Survey, this paper addresses socioeconomic inequalities in the use of outpatient services according to intensity of need. Methods: A three-stage cluster sampling was used to select 5000 adults (18 years and over). The non-response rate was 24.7% and calibration of the natural expansion factors was necessary to obtain the demographic structure of the Brazilian population. Utilization was established by use of outpatient services in the 12 months prior to the interview. Socioeconomic inequalities were analyzed by logistic regression models using years of schooling and private health insurance as independent variables, and controlling by age and sex. Effects of the socioeconomic variables on health services utilization were further analyzed according to self-rated health (good, fair and poor), considered as an indicator of intensity of health care need. Results: Among the 5000 respondents, 63.4% used an outpatient service in the year preceding the survey. The association of health services utilization and self-rated health was significant (p<0.001). Regarding socioeconomic inequalities, the less educated used health services less frequently, despite presenting worse health conditions. Highly significant effects were found for both socioeconomic variables, years of schooling (p<0.001) and private health insurance (p<0.00), after controlling for age and sex. Stratifying by self-rated health, the effects of both socioeconomic variables were significant among those with good health status, but not statistically significant among those with poor self-rated health. Conclusions: The analysis showed that the social gradient in outpatient services utilization decreases as the need is more intense. Among individuals with good self-rated health, possible explanations for the inequality are the lower use of preventive services and unequal supply of health services among the socially disadvantaged groups, or excessive use of health services by the wealthy. On the other hand, our results indicate an adequate performance of the Brazilian health system in narrowing socioeconomic inequalities in health in the most serious situations of need.
Patient related factors in frequent readmissions: the influence of condition,...
by Sue KirbySarah DennisUpali JayasingheMark Harris
20 Jul 2010 at 6:00pm
Background: People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors. Methods: A retrospective analysis was performed on emergency department data from 2003 to 2008 collected from a regional hospital in NSW. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis. Results: The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth. Conclusions: Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.
Using a population-based approach to prevent hepatocellular cancer in New Sou...
by Monica RobotinMelanie KansilJacob GeorgeKirsten HowardSteven TipperMiriam LevyNghi PhungAndrew Penman
20 Jul 2010 at 6:00pm
Background: Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the B Positive pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and the extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area. Methods: Estimated numbers of CHB infections were derived Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program. Results: Assuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into an additional 5 additional appointments per year for each local GP, 25 for each specialist and additional 420 liver ultrasound examinations. Conclusions: While the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.
Provision of relapse prevention interventions in UK NHS Stop Smoking Services...
by Shade AgboolaTim ColemanJo Leonardi-BeeAndy McEwenAnn McNeill
19 Jul 2010 at 6:00pm
Background: UK NHS Stop Smoking Services provide cost effective smoking cessation interventions but, as yet, there has been no assessment of their provision of relapse prevention interventions. Methods: Electronic questionnaire survey of 185 UK Stop Smoking Services Managers Results: Ninety six Stop Smoking Service managers returned completed questionnaires (52% response rate). Of these, 58.3% (n=56) ran NHS Stop Smoking Services which provided relapse prevention interventions for clients with the most commonly provided interventions being behavioural support: telephone (77%), group (73%), and individual (54%). Just under half (48%, n=27) offered nicotine replacement therapy (NRT), 21.4% (n=12) bupropion; 19.6% (n=11) varenicline. Over 80% of those providing relapse prevention interventions do so for over six months. Nearly two thirds of all respondents thought it was likely that they would either continue to provide or commence provision of relapse prevention interventions in their services. Of the remaining respondents, 66.7% (n=22) believed that the government focus on four-week quit rates, and 42.9% (14 services) believed that inadequate funding for provision of relapse prevention interventions, were major barriers to introducing these interventions into routine care. Conclusions: Just over half of UK managers of NHS Stop Smoking Services who responded to the questionnaire reported that, in their services, relapse prevention interventions were currently provided for clients, despite, at that time, there being a weak evidence base for their effectiveness. The most commonly provided relapse prevention interventions were those for which there was least evidence. If these interventions are found to be effective, barriers would need to be removed before they would become part of routine care.
An exploration of the association between very early rehabilitation and outco...
by Hiroki MatsuiHideki HashimotoHiromasa HoriguchiHideo YasunagaShinya Matsuda
19 Jul 2010 at 6:00pm
Background: Very early rehabilitation is expected to improve functional outcomes after stroke, although its effectiveness has not been fully evaluated. The purpose of this study was to investigate the association between very early intervention (VEI), and patient outcomes at discharge by using nationwide large data and statistical treatment for selection bias. Methods: In this study, we defined VEI as rehabilitation commencing within 3 days of stroke admission. The data were derived from a nationwide survey of acute-care hospitals conducted in 2007 for designing a reimbursement scheme and from a concurrent survey on rehabilitation services among a convenient subgroup of hospitals participating in the above survey. We included patients with a diagnosis code of ischaemic cerebrovascular disease with acute onset who underwent any rehabilitation services during hospitalisation. Surgery cases, those with no functional deficit, and those with a severe consciousness deficit upon admission were excluded. A total of 5,482 patients were enrolled from 294 hospitals. To correct for any potential selection bias, we used Friday admission as an instrumental variable (IV) and conducted a bivariate probit model analysis. Results: We found that VEI for acute stroke patients was significantly associated with a lesser degree of disability at discharge. Even after considering endogenous problems due to treatment selection, VEI improved the chance of reducing disability by 15.3% (p<0.001). There was no significant association between VEI and in-hospital mortality, suggesting that VEI was not likely to lead to an adverse outcome. Conclusions: These data suggest that VEI may lead to a better outcome with no increase in adverse events compared to delayed rehabilitation.
Policy maker and provider knowledge and attitudes regarding the provision of ...
by Vanphanom SychareunKeokedthong PhongsavanVisanou HansanaAlongkone Phengsavanh
19 Jul 2010 at 6:00pm
Background: The Ministry of Health (MOH) launched the National Reproductive Health Policy in 2005, which included recommendations regarding the use of emergency contraceptive pills (ECP). However, ECP have not yet been introduced officially in the public sector of the Lao PDR. Thus, their availability is limited. Understanding the knowledge of ECP and attitudes about their provision, barriers to use, and availability among health providers and policy makers is essential to successfully incorporate ECP into reproductive health services. Methods: Qualitative research methods using in-depth interviews were employed to collect data from policy makers and health providers (auxiliary medical staff, nurses, and medical doctors). Altogether, 10 policy makers, 22 public providers, and 10 providers at private clinics were interviewed. Content analysis was applied to analyze the transcribed data. Results: The majority of policy makers and health care providers had heard about ECP and supported their introduction in the public sector. However, their knowledge was poor, many expressed inconsistent attitudes, and their ability to meet the demand of potential users is limited. Conclusions: There is a need to train health providers and policy makers on emergency contraception and improve their knowledge about ECP, especially regarding the correct timing of use and the availability of methods. In addition, the general public must be informed of the attributes, side effects, and availability of ECP, and policy makers must facilitate the approval of ECP by the Lao Food and Drug Administration. These interventions could lead to increased access to and demand for ECP.
Availability and use of essential medicines in China: manufacturing, supply, ...
by Wen ChenShenglan TangJing SunDennis Ross-DegnanAnita Wagner
16 Jul 2010 at 6:00pm
Background: The current health care reform in China launched in 2009 tackles the problem of access to appropriate medicines for its 1.3 billion people by focusing on providing essential medicines to all. To provide evidence for the reform process, we investigated the manufacturing, purchasing, and prescribing of essential medicines in two provinces. Methods: We conducted surveys in 2007 of all manufacturers (n=253) and of 59 purposively selected retail and 63 hospital pharmacies in Shandong and Gansu provinces to assess production and supply of products on the 2004 National Essential Medicines List (NEML), as well as factors underlying decision making about production and supply. We also reviewed prescriptions (n=5456) in health facilities to calculate standard indicators of appropriate medicines use. Results: Overall, manufacturers in Shandong and Gansu produced only 62% and 50%, respectively, of the essential medicines they were licensed to produce. Of a randomly selected 10% of NEML products, retail pharmacies stocked up to 60% of Western products. Median availability in hospital pharmacies ranged from 19% to 69%. Manufacturer and retail pharmacy managers based decisions on medicines production and stocking on economic considerations, while hospital pharmacy managers cited clinical need. Between 64% and 86% of prescriptions contained an essential medicine. However, overprescribing of antibiotics (34%-77% of prescriptions) and injectables (22%-61%) for adult non-infectious outpatient consultations was common. Conclusions: We found that manufacturers, retail pharmacies, and hospital pharmacies paid limited attention to China's 2004 NEML in their decisions to manufacture, purchase, and stock essential medicines. We also found that prescribing of essential medicines was frequently inappropriate. These results should inform strategies to improve affordable access to essential medicines under the current health care reform.
Immigrants and health system challenges to TB control in Oman
by Abdullah Al-ManiriGrethe FochsenOmar Al-RawasAyesha De Costa
15 Jul 2010 at 6:00pm
Background: During the past three decades, Oman has made significant progress in controlling TB within it's borders. However, the national TB control program elimination target has yet to be reached. This study aims to explore the perceived roles played by the immigrant population and the private health sector in relation to TB control in Oman. Methods: We conducted seventeen interviews with different health care providers. The verbatim transcripts were processed using content analysis. Results: Three main themes emerged. Firstly the threat of repatriation faced by underprivileged expatriates, secondly the criticized and forgotten private health sector as a key player and thirdly the user and provider barriers faced by Omani patients in the Omani public health system. Conclusions: The study has identified some of the challenges and barriers to TB control in Oman. These challenges are mainly related to unintended negative consequences arising from the current repatriation policy of immigrants and to and the lack of involvement of the private sector in TB control. TB control strategies designed to address these challenges are needed, for Oman to reach its TB elimination targets.

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