Evaluating variations in medical practice between government primary care health centres.
ABSTRACT We evaluated variations in medical care for diabetes among government health centres in Trinidad and Tobago. Data were analysed for 1579 subjects with clinical diabetes attending 23 health centres concerning 12 processes of care and six case-mix or outcome variables. Random effects models were used for analysis. Health centre level variation was appreciable. Intraclass correlations ranged from 0.025 to 0.316 for process of care variables and 0.000 to 0.056 for case-mix variables. Compared with health centres with only one nurse, patients attending those with three or more nurses received 1.18 (95% confidence interval 0.27 to 2.09) more processes of care. Delivery of medical care varied among the health centres and those with higher staffing levels provided more processes of care.
Article: Universal access to HIV treatment in developing countries: going beyond the misinterpretations of the 'cost-effectiveness' algorithm.[show abstract] [hide abstract]
ABSTRACT: Economic cost-effectiveness analysis (CEA) has been proposed as the appropriate tool to set priorities for resource allocation among available health interventions. Controversy remains about the way CEA should be used in the field of HIV/AIDS. This paper reviews the general literature in health economics and public economics about the use of CEA for priority setting in public health, in order better to inform current debates about resource allocation in the fight against HIV/AIDS. Theoretical and practical limitations of CEA do not raise major problems when it is applied to compare alternatives for treating the same medical condition or public health problem. Using CEA to set priorities among different health interventions by ranking them from the lowest to the highest values of their cost per life-year saved is appropriate only under the very restrictive and unrealistic assumptions that all interventions compared are discrete and finite alternatives that cannot vary in terms of size and scale. In order for CEA to inform resource allocation compared across programmes to fight the AIDS epidemic, a pragmatic interpretation of this economic approach, like that proposed by the Commission on Macroeconomics and Health, is better suited. Interventions, like a number of preventive strategies and first-line antiretroviral treatments for HIV, whose marginal costs per additional life-year saved are less than three times the gross domestic product per capita, should be considered cost-effective. Because of their empirical and theoretical limitations, results of CEA should only be one element in priority setting among interventions for HIV/AIDS, which should also be informed by explicit debates about societal and ethical preferences.AIDS (London, England) 08/2008; 22 Suppl 1:S59-66. · 4.91 Impact Factor
Article: Primary care management of diabetes in a low/middle income country: a multi-method, qualitative study of barriers and facilitators to care.[show abstract] [hide abstract]
ABSTRACT: The management of patients with diabetes mellitus is complex. Some research has been done in developed countries to attempt to determine the factors that influence quality of care of patients with diabetes: Factors thus far postulated are usually categorised into patient, clinician and organisational factors. Our study sought to discover the main barriers and facilitators to care in the management of diabetes in primary care in a low/middle income country. A qualitative study, based on reflexive ethnography using participant observation, semi-structured interviews of clinicians (10) and group interviews with paramedical staff (4) and patients (12) in three purposively sampled health centres, along with informal observation and discussions at over 50 other health centres throughout Tunisia. A content analysis of the data was performed. Over 400 potential barriers or facilitators to care of patients with diabetes in primary care in Tunisia emerged. Overall, the most common cited factor was the availability of medication at the health centre. Other frequently observed organisational factors were the existence of chronic disease clinics and clinicians workload. The most commonly mentioned health professional factor was doctor motivation. Frequently cited patient factors were financial issues, patient education and compliance and attendance issues. There were notable differences in the priority given to the various factors by the researcher, physicians, paramedical staff and the patients. We have discovered a large number of potential barriers and facilitators to care that may potentially be influencing the care of patients with diabetes within primary care in Tunisia, a low/middle income country. An appreciation and understanding of these factors is essential in order to develop culturally appropriate interventions to improve the care of people with diabetes.BMC Family Practice 02/2007; 8:63. · 1.80 Impact Factor
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ABSTRACT: Timeliness of immunisation is important in achieving a protective effect at the individual and population levels. Recent international research has highlighted the importance of organisational features of the health system in timely immunisation. This paper reports on an analysis of the availability of records of timely delivery of childhood immunisations in Indigenous primary care services and organisational features of vaccination programs in different jurisdictions in Australia. The findings demonstrate wide variation in recorded timely delivery of immunisations between health centres within and between jurisdictions. Significant deficiencies in the approach to delivery and recording of immunisations appear to be principally related to fragmented systems of delivery, recording and communication between child health and primary care services. Understanding these deficiencies presents opportunities for improving timely immunisation.Vaccine.