The determination of an appropriate catchment area for a hospital providing highly specialized (i.e. tertiary) health care is typically a trade-off between ensuring adequate client volumes and maintaining reasonable accessibility for all potential clients. This may pose considerable challenges, especially in sparsely inhabited regions. In Finland, tertiary health care is concentrated in five university hospitals, which provide services in their dedicated catchment areas. This study utilizes Geographic Information Systems (GIS), together with grid-based population data and travel-time estimates, to assess the spatial accessibility of these hospitals. The current geographical configuration of the hospitals is compared to a normative assignment, with and without capacity constraints. The aim is to define optimal catchment areas for tertiary hospitals so that their spatial accessibility is as equal as possible. The results indicate that relatively modest improvements can be achieved in accessibility by using normative assignment to determine catchment areas.
To determine the patterns and determinants of mobility in persons with HIV infection or AIDS on a population basis.
Descriptive cross-sectional population health study.
650 full members (i.e., HIV-positive) of the Vancouver Persons with AIDS Society who were residents of British Columbia and who allow the society to include unsolicited material with their monthly newsletter.
Migration history, access to HIV-related care at diagnosis, current and pre-HIV sociodemographic characteristics, and current health status.
Two hundred and fifty-two persons living with HIV/AIDS participated in the study. At the time of the survey, the majority of subjects were male (94 percent), aged between 30 and 54 years (87 percent), and able to carry out daily activities without assistance (84 percent). The median time since the known date of HIV infection was 6 years. Access to care at diagnosis was associated in this population with being diagnosed in the largest metropolitan area in the province (OR = 2.14; 95 percent CI: 1.18, 3.87), a pre-HIV income of $30,000 or more per annum (OR = 0.49; 95 percent CI: 0.27, 0.89), a known date of diagnosis prior to 1990 (78 percent versus 64 percent; p = 0.019), and living in the same residence from the date of known HIV diagnosis to the date of the survey (63 percent versus 51 percent; p = 0.024).
Although no definitive causal association can be provided by this cross-sectional analysis, our results clearly highlight several ways in which the need for treatment and care potentially affect where persons with HIV/AIDS choose to live.
Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.
Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.
ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27?day mean deviation, 99% CI?=?±14.6), psychiatric diagnosis (13?day mean deviation, 99% CI?=?±6.2), abusive behaviours (12?day mean deviation, 99% CI?=?±10.7), and stroke (7?day mean deviation, 99% CI?=?±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.
A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.
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Immigrants from non-Western countries occupy a fifth of the beds in an acute psychiatric department. There is a prevailing clinical impression that they have higher morbidity than the traditional Norwegian population. MATERIAL: A one-year cohort of patients, n = 415, was retrospectively investigated, 80 of whom had a non-Western background. RESULTS: The proportion of immigrant patients from the department's catchment area was 49 in 10 000, compared to 52 in 10 000 for traditional Norwegian patients, p = 0.72. Significantly more of the immigrants were men, they were younger, they got more compulsory treatment, and more often a diagnosis of psychosis, but they had less substance abuse problems. Suicidality was evenly distributed in both groups. INTERPRETATION: Our clinical impression of a higher frequency of referral of immigrants was not substantiated. However, it is suggested that immigrants have greater difficulties in presenting their psychiatric problems to a general practitioner; hence they probably develop more severe symptoms before referral. The low incidence of referral of female immigrants could indicate a higher level of functioning, or cultural barriers to exhibiting problems.
Comment In: Tidsskr Nor Laegeforen. 2004 May 6;124(9):1278; author reply 127815131720
This descriptive epidemiology study reports the cancer incidence and mortality experience of Northeastern Ontario residents during the 8-year period from 1991-1998.
Standardized Incidence Ratios (SIRs), Standardized Mortality Ratios (SMRs) and 95% confidence intervals (CI) were calculated for a number of cancer sites (n = 25 for males, n = 26 for females), using rates determined from the Ontario population as the referent population.
During the period 1991-1998, 24,019 cases of primary incident cancers (excluding non-melanotic skin cancer) and 11,677 deaths attributed to cancer occurred in Northeastern Ontario residents. Several cancer sites were significantly elevated in Northeastern Ontario residents. For example, trachea-bronchus-lung cancer incidence and mortality rates were significantly elevated. Rates were over 20% higher than those for the province of Ontario, for both males and females (SIR = 122, 95% CI = 118-127; SIR = 123, 95% CI = 117-129 for males and females, respectively; SMR = 125, 95% CI = 120-130; SMR = 125, 95% CI = 118-132 for males and females, respectively).
For both males and females, the cancer incidence and mortality experience of residents of Northeastern Ontario were significantly higher than would be expected based on Ontario cancer rates, overall, and for a number of individual sites. While this study does not identify causal associations between risk factors and disease, these data should aid in cancer control planning, and generating hypotheses for further study.
The aim of the study was to investigate the relationship between mortality from cardiovascular diseases (CVD) and socio-economic status (SES) in Sweden and to estimate to what extent the difference between a province with low mortality and the rest of Sweden was dependent on socio-economic factors. A population-based retrospective study with a historical prospective approach was performed covering a 10-y period in the province of Halland, Sweden, as well as Sweden as a whole. Altogether 1,654,744 men and 1,592,467 women were included, of whom 45,394 men and 43,403 women were from Halland, distributed according to SES. Multivariate analysis with Poisson regression was used. Relative risks with 95% confidence intervals were calculated. Both men and women with a low SES showed a significantly higher risk of death from CVD in Sweden as a whole. The risk was 23% higher for male blue-collar workers and 44% higher for female blue-collar workers when compared to their white-collar counterparts. The level of mortality in Halland was 14% lower compared to the country as a whole when only age was taken into account. When the socio-economic variable was also included, this figure was 8%. The results show the substantial significance of social differences with respect to CVD mortality. The effect of SES seems to be more important than that of geographical conditions when the latter are isolated from socio-economic influence.
With standard community resources, managing some patients with long-term mental illness can prove difficult, given the high level of care required. How many beds do such patients require? The study examined the prevalence, diagnostic and behavioral characteristics, and residential arrangements of a cohort of these patients in a semirural area of Canada (population of 291,500). The area has always functioned without a psychiatric hospital.
A cross-sectional inquiry was made of all relevant institutions and residential facilities (including the local jail and shelters). Key stakeholders were interviewed and provincial databases were accessed in an effort to identify all adults aged 18 to 65 originating from the catchment area who displayed both a psychotic illness and severe behavioral disturbance necessitating ongoing close supervision. The Riverview Psychiatric Inventory was used to describe and quantify behavioral problems.
Thirty-six patients met the study criteria, for a prevalence of 12.4 per 100,000 in the general population. Most resided in a publicly funded nursing home or a well-staffed rural group home. Four (prevalence of 1.4 per 100,000) had a forensic profile, needed secure settings, and were long-term residents on acute care wards. Only one patient had transferred to a psychiatric hospital outside the catchment area.
Care for this population can be provided outside conventional psychiatric institutions but requires highly supervised long-term residential services in the range of ten to 40 per 100,000 in the population, depending on area characteristics, with urban, socially deprived areas likely having higher needs.
We examined the epidemiology of esophageal cancer in Finland and the role of the surveillance of Barrett's esophagus (BE) in detecting esophageal adenocarcinoma (EA) in our own hospital referral area. We observed that the incidence of EA in men has increased tenfold from the 1970s and was 1.10/100,000/year in 1998-2002. In women, a 4.5-fold increase was observed (incidence 0.11/100,000/year). In 1998-2002, the mean annual number of new EA cases was 57.4 (79.8% men) in Finland with a population of 5.2 million. In our hospital referral area with a mean population of 261 349, 11 EAs were observed in 1996-2001. Of them, two (18.2%) had BE. One EA was detected during surveillance. EA comprised 0.05% of all causes of deaths in our hospital referral area. We conclude that EA incidence has increased significantly in men in Finland, but still EA is seldom detected on BE surveillance. EA is an uncommon cause of death in our hospital referral area.
The optimal treatment of patients with substance use disorders (SUDs) requires an awareness of their comorbid mental disorders and vice versa. The prevalence of comorbidity in first-time-admitted SUD patients has been insufficiently studied. Diagnosing comorbidity in substance users is complicated by symptom overlap, symptom fluctuations, and the limitations of the assessment methods. The aim of this study was to diagnose all mental disorders in substance users living in a single catchment area, without any history of treatment for addiction or psychiatric disorders, admitted consecutively to the specialist health services. The prevalence of substance-induced versus substance-independent disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), in SUD patients will be described.
First-time consecutively admitted patients from a single catchment area, aged 16 years or older, admitted to addiction clinics or departments of psychiatry as outpatients or inpatients will be screened for substance-related problems using the Alcohol Use Disorder Identification Test and the Drug Use Disorder Identification Test. All patients with scores above the cutoff value will be asked to participate in the study. The patients included will be diagnosed for SUD and other axis I disorders by a psychiatrist using the Psychiatric Research Interview for Substance and Mental Disorders. This interview was designed for the diagnosis of primary and substance-induced disorders in substance users. Personality disorders will be assessed according to the Structured Clinical Interview for DSM-IV axis II disorders. The Symptom Checklist-90-Revised, the Inventory of Depressive Symptoms, the Montgomery Asberg Depression Rating Scale, the Young Mania Rating Scale, and the Angst Hypomania Check List will be used for additional diagnostic assessments. The sociodemographic data will be recorded with the Stanley Foundation's Network Entry Questionnaire. Biochemical assessments will reveal somatic diseases that may contribute to the patient's symptoms.
This study is unique because the material represents a complete sample of first-time-admitted treatment seekers with SUD from a single catchment area. Earlier studies have not focused on first-time-admitted patients, so chronically ill patients, may have been overrepresented in those samples. This study will contribute new knowledge about mental disorders in first-time-admitted SUD patients.
Cites: Int Clin Psychopharmacol. 2004 Jan;19(1):1-715101563
In geographical studies, population distribution is a key issue. An unequal distribution across units of analysis might entail extra-variation and produce misleading conclusions on healthcare performance variations. This article aims at assessing the impact of building more homogeneous units of analysis in the estimation of systematic variation in three countries.
Hospital discharges for six conditions (congestive heart failure, short-term complications of diabetes, hip fracture, knee replacement, prostatectomy in prostate cancer and percutaneous coronary intervention) produced in Denmark, England and Portugal in 2008 and 2009 were allocated to both original geographical units and new ad hoc areas. New areas were built using Ward's minimum variance methods. The impact of the new areas on variability was assessed using Kernel distribution curves and different statistic of variation such as Extremal Quotient, Interquartile Interval ratio, Systematic Component of Variation and Empirical Bayes statistic.
Ward's method reduced the number of areas, allowing a more homogeneous population distribution, yet 20% of the areas in Portugal exhibited less than 100 000 inhabitants vs. 7% in Denmark and 5% in England. Point estimates for Extremal Quotient and Interquartile Interval Ratio were lower in the three countries, particularly in less prevalent conditions. In turn, the Systematic Component of Variation and Empirical Bayes statistic were slightly lower in more prevalent conditions.
Building new geographical areas produced a reduction of the variation in hospitalization rates in several prevalent conditions mitigating random noise, particularly in the smallest areas and allowing a sounder interpretation of the variation across countries.