Cancer survivors with self-reported late effects: their health status, care needs and service utilisation

OBJECTIVE: Cancer survivors (CSs) are at risk of developing late effects (LEs) associated with the disease and its treatment. This paper compares the health status, care needs and use of health services by CSs with LEs and CSs without LEs.

METHODS: Cancer survivors (n = 613) were identified via the Northern Ireland Cancer Registry and invited to participate in a postal survey that was administered by their general practitioner. The survey assessed self-reported LEs, health status, health service use and unmet care needs. A total of 289 (47%) CSs responded to the survey, and 93% of respondents completed a LEs scale.

RESULTS: Forty-one per cent (111/269) of CSs reported LEs. Survivors without LEs and survivors with LEs were comparable in terms of age and gender. The LEs group reported a significantly greater number of co-morbidities, lower physical health and mental health scores, greater overall health service use and more unmet needs. Unadjusted logistic regression analysis found that cancer site, time since diagnosis and treatment were significantly associated with reporting of LEs. CSs who received combination therapies compared with CSs who received single treatments were over two and a half times more likely to report LEs (OR = 2.63, 95% CI = 1.32-5.25) after controlling for all other variables.

CONCLUSIONS: The CS population with LEs comprises a particularly vulnerable group of survivors who have multiple health care problems and needs and who require tailored care plans that take account of LEs and their impact on health-related quality of life.

Evaluation of a partnership between primary and secondary care providing an accessible Level 1 sexual health service in the community

Comprehensive testing for asymptomatic sexually transmitted infections in Northern Ireland has traditionally been provided by genitourinary medicine clinics. As patient demand for services has increased while budgets have remained limited, there has been increasing difficulty in accommodating this demand. In May 2013, the newly commissioned specialist Sexual Health service in the South Eastern Trust sought to pilot a new model of care working alongside a GP partnership of 12 practices. A training programme to enable GPs and practice nurses to deliver Level 1 sexual health care to heterosexual patients aged >16 years, in accordance with the standards of BASHH, was developed. A comprehensive care pathway and dedicated community health advisor supported this new model with close liaison between primary and secondary care. Testing for Chlamydia, gonorrhoea, HIV and syphilis was offered. The aims of the pilot were achieved, namely to provide accessible, cost-effective sexual health care within a framework of robust clinical governance. Furthermore, it uncovered a high positivity rate for Chlamydia, especially in young men attending their general practice, and demonstrated a high level of patient satisfaction. Moreover the capacity of secondary care to deliver Levels 2 and 3 services was increased.

Improving the oral health status of functionally independent and dependent seniors residing in long-term care facilities through dental hygiene education /

The purpose of this study was to evaluate the oral health status of residents residing in 2 long-term care facilities and determine if dental hygiene education was required in order to improve their current oral health. The oral health status of 6 independent and 4 dependent individuals residing in 2 long-term care facilities was evaluated. In addition, the current oral health and disease prevention practices employed by 4 caregivers who were responsible for providing oral care to dependent residents in the long-term care facilities were evaluated. Furthermore, an evaluation of the oral care practices of independent residents who were responsible for providing their own care was conducted. Finally, the challenges that caregivers and independent residents faced when performing oral care were determined, and methodological changes were proposed. Using a generic qualitative research methodology, data collection was comprised of semi structured interviews, field observations, and documentation. The oral health status of the residents was reevaluated 3 months later. The findings of this study demonstrated an increase in plaque accumulation, gingival inflammation, and unhealthy gingival tissue colour changes among the residents over the 3-month period. The study revealed that poor oral health among the residents was a result of inadequate oral hygiene care techniques, difficulties accessing oral health care, financial limitations, insufficient care staff, insufficient time for personal care duties, lack of professional development, minimal interprofessional collaboration of health disciplines, and lack of perseverance on the part of the caregivers and residents. Overall, oral health is essential, and maintaining optimal oral health requires increased collaboration and communication between health care providers.

Financial protection for the poor in Colombia: the effects of a subsidized health insurance scheme

Financial protection is one of the objectives of health systems, which protects poor households from falling into poverty as a result of health care related expenses. Expanding prepayment schemes to the poor is difficult in developing countries because labor is largely informal. Providing health care free-at-point-of-service does not adequately target spending on the poorest, but occupation- or community-based schemes have also inherent limitations to achieve universal coverage. Colombia adopted a government-subsidized health insurance scheme (SHI) strategy. The political debate about increasing SHI enrollment needs evidence about the effectiveness of this scheme regarding financial protection. This study runs a four-part model to estimate the effect of SHI on out-of-pocket expenses by the poor that are currently uninsured, if they were enrolled in the SHI. The results show a 43% and 50% reduction in expenses at Bogotá and national level respectively, which confirms the effectiveness of SHI as a financial protection tool.

Exploratory economic analyses of two primary care mental health projects : implications for sustainability

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions.

Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists.

Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio.

The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

The phenomenon of resilience in crisis care mental health clinicians

The purpose of this study, undertaken in 2003, was to explore the phenomenon of resilience as experienced by Australian crisis care mental health clinicians working in a highly demanding, complex, specialized and stressful environment. For the purpose of this research, the term 'resilience' was defined as the ability of an individual to bounce back from adversity and persevere through difficult times. The six participants for this study were drawn from Melbourne metropolitan mental health organizations – the disciplines of nursing, allied health and medicine. A number of themes were explicated from the participants' interview transcripts – Participants identified the experience of resilience through five exhaustive descriptions, which included: 'The team is a protective veneer to the stress of the work'; Sense of self; Faith and hope; Having insight; and Looking after yourself. These exhaustive descriptions were integrated into a fundamental structure of resilience for clinicians in this role. The study's findings have the potential to inform organizations in mental health to promote resilience in clinicians, with the potential to reduce the risk of burnout and hence staff attrition, and promote staff retention and occupational mental health.

A qualitative study exploring barriers to a model of shared care for pre-school children`s oral health

Objective To explore the oral health beliefs and practices of primary health care professionals which may act as barriers to the development of a model of shared care for the oral health of pre-school children.

Design Qualitative focus group discussions and semi-structured interviews.

Setting Four rural local government areas in Victoria, Australia, 2003.

Subjects and methods Subjects: maternal and child health nurses, general medical practitioners, dental professionals and paediatricians working in the four local government areas. Data collection: discipline specific focus groups and semi-structured interviews. Data analysis: transcription, coding, clustering and thematic analysis.

Results Several strong themes emerged from the data. All participants agreed that dental caries is a significant health issue for young children and their families. Beliefs about the aetiology of dental caries and its prevention were variable and often simplistic, focusing predominantly on diet. Dental professionals did not believe that they had a primary role in the oral health of pre-school aged children but that others particularly maternal and child health nurses did. However other health care professionals were not confident in assuming this role.

Conclusions This study has identified important barriers and possible strategies for the development of an integrated and shared approach to preventing dental caries in pre-school aged children. Clear and consistent oral health information and agreed roles and responsibilities need to be developed.

Evaluation of a community-based mental health drug and alcohol nurse in the care of people living with HIV/AIDS

There is a growing need for advanced practice mental health and drug and alcohol nursing roles in the care of people living with HIV/AIDS; however, limited publications address these domains. This study evaluated a community-based mental health drug and alcohol nurse role caring for people living with HIV/AIDS (Mental Health D&A Nurse) in a large not-for-profit district nursing organization providing care to people living with HIV/AIDS in an Australian city. Outcomes from a client assessment and 6–8-week follow-up by the Mental Health D&A Nurse are presented as captured by the Depression Anxiety Stress Scales (DASS 21), Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Health of the Nation Outcome Scales (HONOS) and WHOQoL BREF. Mean scores and caseness were analysed, and significant differences were found on the 'impairment' and 'social problems' subscales of the HONOS. Results of semi-structured interviews with clients describe effective and supportive mental health care and health-promoting education following visits by the Mental Health D&A Nurse. These positive findings support continuing implementation of the role within this community setting and indicate that even greater benefits will ensue as the role develops further. Findings are of interest to clinicians and policy makers seeking to implement similar roles in community-based HIV/AIDS care.

Effect of type and severity of intimate partner violence on women's health and service use : findings from a primary care trial of women afraid of their partners

Intimate partner violence (IPV) has major affects on women’s wellbeing. There has been limited investigation of the association between type and severity of IPV and health outcomes. This article describes socio-demographic characteristics, experiences of abuse, health, safety, and use of services in women enrolled in the Women’s Evaluation of Abuse and Violence Care (WEAVE) project. We explored associations between type and severity of abuse and women’s health, quality of life, and help seeking. Women (aged 16–50 years) attending 52 Australian general practices, reporting fear of partners in last 12 months were mailed a survey between June 2008 and May 2010. Response rate was 70.5% (272/386). In the last 12 months, one third (33.0%) experienced Severe Combined Abuse, 26.2% Physical and Emotional Abuse, 26.6% Emotional Abuse and/or Harassment only, 2.7% Physical Abuse only and 12.4% scored negative on the Composite Abuse Scale. A total of 31.6% of participants reported poor or fair health and 67.9% poor social support. In the last year, one third had seen a psychologist (36.6%) or had 5 or more general practitioner visits (34.3%); 14.7% contacted IPV services; and 24.4% had made a safety plan. Compared to other abuse groups, women with Severe Combined Abuse had poor quality of life and mental health, despite using more medications, counseling, and IPV services and were more likely to have days out of role because of emotional issues. In summary, women who were fearful of partners in the last year, have poor mental health and quality of life, attend health care services frequently, and domestic violence services infrequently. Those women experiencing severe combined physical, emotional, and sexual abuse have poorer quality of life and mental health than women experiencing other abuse types. Health practitioners should take a history of type and severity of abuse for women with mental health issues to assist access to appropriate specialist support.

The health profile of people living with Parkinson's Disease managed in a comprehensive care setting

Background: Globally there are few reports of the impairments, disabilities and medications used in people living with idiopathic Parkinson’s disease. Caregiver characteristics and caregiver burden have seldom been reported. We examined the health status in a large cohort of people living with Parkinson’s disease and their caregivers managed in a comprehensive health care setting.

Methods/Design: A prospective, cross sectional analysis of impairments, disabilities and Parkinson’s disease medication use was conducted in a sample of 100 people with Parkinson’s disease rated I-IV on the modified Hoehn & Yahr scale. Participants were recruited from the Victorian Comprehensive Parkinson Program in Melbourne, Australia. Their caregivers were invited to provide their views on the burden of care, services provided and support received.

Results: The severity of impairments and disabilities was strongly associated with disease duration (mean of 5.5 years). Those with long standing disease or more severe disease also used more Parkinson’s disease medications and participated in fewer social roles than people who were newly diagnosed or mildly affected. The severity of impairments was strongly correlated with limitations in performing activities of daily living. Limitations in performing daily activities were also found to be a significant contributing factor for health-related quality of life (PDQ-39 SI β=0.55, p=0.000; EQ-5D SI β=0.43, p=0.001). People with Parkinson’s disease lived at home with relatives. The average caregiver was a spouse or child providing approximately 3.5 hours of care per day, with the capacity to provide 9.4 hours per day and had provided care for four years. Additional support was high (63%) for 2.5 hours per day.

Conclusion: The comprehensive care setting of this cohort describes a relatively benign condition despite a wide range of disease duration and severity. This report provides a baseline with which to compare other delivery models.

Influence of body mass index on prescribing costs and potential cost savings of a weight management programme in primary care

Objectives Prescribed medications represent a high and increasing proportion of UK health care funds. Our aim was to quantify the influence of body mass index (BMI) on prescribing costs, and then the potential savings attached to implementing a weight management intervention.

Methods Paper and computer-based medical records were reviewed for all drug prescriptions over an 18-month period for 3400 randomly selected adult patients (18–75 years) stratified by BMI, from 23 primary care practices in seven UK regions. Drug costs from the British National Formulary at the time of the review were used. Multivariate regression analysis was applied to estimate the cost for all drugs and the ‘top ten’ drugs at each BMI point. This allowed the total and attributable prescribing costs to be estimated at any BMI. Weight loss outcomes achieved in a weight management programme (Counterweight) were used to model potential effects of weight change on drug costs. Anticipated savings were then compared with the cost programme delivery. Analysis was carried out on patients with follow-up data at 12 and 24 months as well as on an intention-to-treat basis. Outcomes from Counterweight were based on the observed lost to follow-up rate of 50%, and the assumption that those patients would continue a generally observed weight gain of 1 kg per year from baseline.

Results The minimum annual cost of all drug prescriptions at BMI 20 kg/m2 was £50.71 for men and £62.59 for women. Costs were greater by £5.27 (men) and £4.20 (women) for each unit increase in BMI, to a BMI of 25 (men £77.04, women £78.91), then by £7.78 and £5.53, respectively, to BMI 30 (men £115.93 women £111.23), then by £8.27 and £4.95 to BMI 40 (men £198.66, women £160.73). The relationship between increasing BMI and costs for the top ten drugs was more pronounced. Minimum costs were at a BMI of 20 (men £8.45, women £7.80), substantially greater at BMI 30 (men £23.98, women £16.72) and highest at BMI 40 (men £63.59, women £27.16). Attributable cost of overweight and obesity accounted for 23% of spending on all drugs with 16% attributable to obesity. The cost of the programme was estimated to be approximately £60 per patient entered. Modelling weight reductions achieved by the Counterweight weight management programme would potentially reduce prescribing costs by £6.35 (men) and £3.75 (women) or around 8% of programme costs at one year, and by £12.58 and £8.70, respectively, or 18% of programme costs after two years of intervention. Potential savings would be increased to around 22% of the cost of the programme at year one with full patient retention and follow-up.

Conclusion Drug prescriptions rise from a minimum at BMI of 20 kg/m2 and steeply above BMI 30 kg/m2. An effective weight management programme in primary care could potentially reduce prescription costs and lead to substantial cost avoidance, such that at least 8% of the programme delivery cost would be recouped from prescribing savings alone in the first year.

Care arrangements for people with dementia in developing countries

Background: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. Methods: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. Results: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. Conclusions: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world. Copyright © 2004 John Wiley & Sons, Ltd.