Abstract Purpose Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health ...centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe. Methods This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT–Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models. Results One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P = .007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition ( P <.001), having medical insurance (P = .006), and a self-reported good health status ( P <.001). Conclusions This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background Certain subgroups have higher rates of false fecal immunochemical test (FIT) results, yet few studies have addressed this topic. Objective To identify demographic factors associated with ...false-positive and false-negative FIT results in colorectal cancer screening. Design Retrospective database review of prospectively collected data. Setting A bowel cancer screening center in Hong Kong invited participants for colorectal cancer screening (2008-2012). Patients Study participants who underwent both FIT and colonoscopy in the first year (n = 4482) and underwent colonoscopy after negative FIT results for 3 consecutive years (n = 857). Main Outcome Measurements The diagnostic accuracy and predictive values of FIT according to participant characteristics. Results The sensitivity, specificity, positive predictive values, and negative predictive values for advanced neoplasia were 33.1%, 91.9%, 19.0%, and 96.0%, respectively. Participants 66 to 70 years of age had higher sensitivity, whereas older age, smoking, and use of aspirin/nonsteroidal anti-inflammatory drugs were associated with lower specificity. The rates of false-positive and false-negative results were 8.1% and 66.9%, respectively. Older age (66-70 years; adjusted odds ratio AOR 1.95; 95% confidence interval CI, 1.35-2.81; P < .001), smoking (AOR 1.68; 95% CI, 1.08-2.61; P = .020), and the presence of polypoid adenoma (AOR 1.71; 95% CI, 1.14-2.57; P = .009) were associated with false-positive results. Younger participants (AOR for elderly participants 0.31) and the use of aspirin/nonsteroidal anti-inflammatory drugs (AOR 4.44) in participants with 1 FIT with negative results and the absence of high-grade dysplasia (AOR for presence 0.41) were associated with false-negative results. Limitations Self-referred participants who received one type of qualitative FIT. Conclusion These findings could be used to target screening more toward those with a higher risk of false-negative results and those with a lower risk of false-positive results for earlier colonoscopy.
Targeted screening for colorectal cancer in high-risk individuals Wong, Martin C.S., MBChB, MD, MPH, FRACGP; Wong, Sunny H., MBChB (Hons), DPhil; Ng, Siew C., MBBS, PhD ...
Baillière's best practice & research. Clinical gastroenterology,
12/2015, Letnik:
29, Številka:
6
Journal Article
Recenzirano
Abstract The idea of targeted screening for colorectal cancer based on risk profiles originates from its benefits to improve detection yield and optimize screening efficiency. Clinically, it allows ...individuals to be more aware of their own risk and make informed decisions on screening choice. From a public health perspective, the implementation of risk stratification strategies may better justify utilization of colonoscopic resources, and facilitate resource-planning in the formulation of population-based screening programmes. There are several at-risk groups who should receive earlier screening, and colonoscopy is more preferred. This review summarizes the currently recommended CRC screening strategies among subjects with different risk factors, and introduces existing risk scoring systems. Additional genetic, epidemiological, and clinical parameters may be needed to enhance their performance to risk-stratify screening participants. Future research studies should refine these scoring systems, and explore the adaptability, feasibility, acceptability, and user-friendliness of their use in clinical practice among different population groups.
Background The Asia-Pacific Colorectal Screening (APCS) score based on age, gender, family history, and smoking is useful to predict advanced colorectal neoplasia (ACN) in asymptomatic Asian ...subjects. Purpose To evaluate the factors in addition to those of APCS associated with ACN colonoscopic findings. Methods Data from 5,220 asymptomatic subjects aged between 50 and 70 years who underwent screening colonoscopy in a community center between 2008 and 2012 were analyzed. One binary logistic regression analysis was conducted in 2013 with the presence of ACN or cancer as the outcome, controlling for APCS score, alcohol consumption, BMI, hypertension, and other chronic diseases as independent variables. Results The average participant age was 57.7 years (SD=4.9) and 47.5% were men. Advanced neoplasms or cancers were identified at colonoscopy in 5.6% of all screening participants. From multivariate regression analysis, APCS score≥4 (adjusted OR AOR=1.74, 95% CI=1.34, 2.25, p <0.001); overweight (BMI=23−24.9, AOR=1.52, 95% CI=1.12, 2.07, p =0.007); obesity (BMI≥25, AOR=1.56, 95% CI=1.15, 2.10, p =0.004); hypertension (AOR=1.58, 95% CI=1.21, 2.06, p =0.001); and alcohol consumption (AOR=1.47, 95% CI=1.05, 2.06, p =0.025) were associated with ACN. The c-statistic of APCS score alone was 0.560 (95% CI=0.524, 0.595, p =0.001) and that of APCS score plus BMI, hypertension, and alcohol consumption was 0.613 (95% CI=0.578, 0.648, p <0.001). Conclusions Alcohol consumption, hypertension, and BMI are independent predictors of ACN, which could be incorporated into the APCS for prioritizing Asian asymptomatic subjects for colorectal cancer screening.
Background and Aims Current evidence of whether distal hyperplastic polyps (HPs) are markers of proximal neoplasia (PN) is mixed. We evaluated the association between distal neoplasia and synchronous ...PN in asymptomatic subjects. Methods We recruited 5819 Chinese asymptomatic screening participants 50 to 70 years of age who underwent colonoscopy in Hong Kong from 2008 to 2014, of whom 206 subjects with distal advanced neoplasia or cancer were excluded. The association between distal pathology (tubular adenomas TAs, HPs, no polyps) and proximal pathology (PN, proximal advanced neoplasia PAN) was assessed by multivariate regression models, overall and stratified by the Asia Pacific Colorectal Screening scoring system (scores of 4-7, high risk; scores of 0-3, lower risk). Results The prevalence of PN in the no distal polyps group, distal HPs group, and distal TAs group was 14.8%, 19.3%, and 29.4%, respectively. The corresponding prevalence of PAN was 1.8%, 3.2%, and 3.5%. Participants with distal HPs did not have significantly higher odds of PN (adjusted odds ratio AOR 1.24; 95% confidence interval CI, 0.97-1.59; P = .089), and their association with PAN was marginally significant (AOR 1.77; 95% CI, 1.00-3.13; P = .052), except in lower risk subjects for whom the odds of PAN were marginally higher in the distal HPs group than the no distal polyps group (AOR 1.97; 95% CI, 1.01-3.85; P = .048). Overall, the distal polyps group had significantly lower odds of PN than the distal TAs group (AOR 0.55; 95% CI, 0.40-0.76; P < .001). The increased risk of PN and PAN among those with distal HPs was modest. Conclusions A direct association between distal HPs and PN is lacking, and this implies a need for a multivariate assessment of the risk of PAN. Recommending colonoscopy for every patient with distal HPs detected by screening sigmoidoscopy is not supported by this study.
Objective To assess depression in children with chronic kidney disease and to determine associations with patient characteristics, intellectual and educational levels, and health-related quality of ...life (HRQoL). Study design Subjects aged 6-17 years from the Chronic Kidney Disease in Children cohort study completed the Children's Depression Inventory (CDI), Wechsler Abbreviated Scales of Intelligence, Wechsler Individual Achievement Test-II-Abbreviated, and the Pediatric Inventory of Quality of Life Core Scales 4.0. Regression analyses determined associations of CDI score and depression status with subject characteristics, intellectual and educational levels, and HRQoL. A joint linear mixed model and Weibull model were used to determine the effects of CDI score on longitudinal changes in glomerular filtration rate and time to renal replacement therapy. Results A total of 344 subjects completed the CDI. Eighteen (5%) had elevated depressive symptoms, and another 7 (2%) were being treated for depression. In adjusted analyses, maternal education beyond high school was associated with 5% lower CDI scores (estimate, 0.95; 95% CI, 0.92-0.99). Depression status was associated with lower IQ (99 vs 88; P = .053), lower achievement (95 vs 77.5; P < .05), and lower HRQoL by parent and child reports (effect estimates, −15.48; 95% CI, −28.71 to −2.24 and −18.39; 95% CI, −27.81 to −8.96, respectively). CDI score was not related to change in glomerular filtration rate. Conclusion Children with depression had lower psychoeducational skills and worse HRQoL. Identifying and treating depression should be evaluated as a means of improving the academic performance and HRQoL of children with chronic kidney disease.
Abstract Background Dyslipidemia is a significant health problem, and persistent use of lipid-lowering agents among dyslipidemic patients is clinically important. However, few studies have evaluated ...the profiles of medication discontinuation among ethnic Chinese patients. Objective The objective of this study was to evaluate the level of medication adherence among Chinese patients who were prescribed a lipid-lowering drug and to investigate factors that could help physicians identify patients at risk for discontinuing their medication. Methods All patients who attended any primary care clinic in 1 territory of Hong Kong and were prescribed at least 1 lipid-lowering agent from January 2004 to June 2007 were included. The incidences of drug discontinuation within 180 days after drug prescriptions were measured, and the factors associated with discontinuation using binary logistic regression analyzes were evaluated. Results Of the 12,875 eligible patients, the majority were prescribed fibrates (54.4%) and statins (45.1%). Among the patients, 17.0% discontinued their medication. Older patients (adjusted odds ratio aOR = 0.72–0.79 for patients >50 years), male subjects (aOR = 0.87; 95% CI, 0.78–0.97; P = 0.009), fee payers (aOR = 0.88; 95% CI, 0.78–0.99; P = 0.029), attendees in family medicine specialist clinics (aOR = 0.82; 95% CI, 0.70–0.96; P = 0.013), residents in rural districts (aOR = 0.52; 95% CI, 0.44–0.60; P < 0.001), follow-up visitors (aOR = 0.60; 95% CI, 0.54–0.66; P < 0.001), patients with comorbidities (aOR = 0.39; 95% CI, 0.35–0.44; P < 0.001 for 1 comorbidity and aOR = 0.28; 95% CI, 0.25–0.33; P < 0.001 for at least 2 comorbidities), and persons who use fibrates (aOR = 0.56; 95% CI, 0.49–0.64; P < 0.001) were significantly less likely to discontinue their medication. Conclusions The findings of these associated factors were new for ethnic Chinese patients. These findings could help physicians identify patients who had been prescribed a lipid-lowering agent who were at higher risk of discontinuing their medication. Their medication-taking behavior should be monitored more closely, and future studies should evaluate the reasons of drug discontinuation.
Abstract Background: Although poor control of hypertension is a problem worldwide, most published studies of adherence to antihypertensive medications have involved only white subjects. Objective: ...This study examined levels of and factors associated with short-term adherence to β-blocker therapy among a representative sample of ethnic Chinese patients with hypertension from a large territory in Hong Kong. Methods: Data for all hypertensive patients aged ≥18 years who received a prescription for a β-blocker at a visit to any public primary care clinic in the New Territory East cluster of Hong Kong and made at least 1 subsequent visit for a refill of this prescription between January 2004 and June 2007 were obtained from a validated clinical database generalizable to the Chinese population. The proportion of patients who were adherent to β-blocker therapy was measured based on the medication possession ratio (MPR), calculated over 2 consecutive visits. Good adherence was defined as an MPR ≥80%. Factors potentially associated with adherence to β-blockers were investigated using multivariable logistic regression analysis, with adjustment for age, sex, payment status, service type, district of residence, visit type, and number of comorbidities. Results: Data were obtained for 15,918 eligible patients (62.2% female; mean age, 59.1 years). Of these patients, 81.3% were adherent to β-blocker therapy. Factors associated with a greater likelihood of good adherence to β-blocker therapy were age ≥50 years (adjusted odds ratio AOR, age 50–59 years = 1.53 95% CI, 1.38–1.70; AOR, age 60–69 years = 1.85 95% CI, 1.64–2.10; AOR, age ≥70 years = 1.88 95% CI, 1.66–2.12; all, P < 0.001); fee paid versus fee waived (AOR = 1.16 95% CI, 1.06–1.28; P = 0.001); attendance at a family medicine specialist clinic (AOR = 1.30 95% CI, 1.09–1.54; P = 0.003); and follow-up visit versus new-patient visit (AOR = 2.67 95% CI, 2.42–2.95; P < 0.001). Conclusion: Among these Chinese patients with hypertension, younger patients, those whose fees were waived, and those who were newly prescribed a β-blocker had a greater likelihood of being nonadherent.
Effects of Obesity in Rectal Cancer Surgery Chern, Hueylan, MD; Chou, Joanne, MPH; Donkor, C., MD ...
Journal of the American College of Surgeons,
07/2010, Letnik:
211, Številka:
1
Journal Article
Recenzirano
Background Increased local recurrence after total mesorectal excision (TME) in obese rectal cancer patients has been attributed to technical difficulties associated with adiposity. In this study, we ...evaluate whether higher body mass index (BMI) compromises surgical resection in patients with locally advanced, mid-to-low rectal cancer after neoadjuvant therapy, adversely affecting long-term oncologic outcomes. Study Design Five-hundred and ninety-six patients with uT3/4 and/or uN1 rectal adenocarcinoma were treated from 1998 to 2007 with neoadjuvant therapy, followed by radical resection using TME. Outcomes were analyzed according to BMI: obese (BMI ≥30) and nonobese (BMI <30). Median follow-up was 39 months. Results In all, 26.7% of patients were obese. The rate for positive circumferential margin in nonobese was 4.9% versus 2.5% in obese (p = 0.21). The sphincter-sparing rate in nonobese was 79.5% versus 80.5% in obese (p = 0.77). Five-year overall survival for nonobese was 84% versus 90% for obese (p = 0.92). Five-year disease-free survival for nonobese was 76% versus 73% for obese (p = 0.75). Operative time was longer in obese than nonobese; 4.3 versus 3.7 hours, respectively (p < 0.01). Length of stay was longer in obese than nonobese; 8 versus 7 days, respectively (p < 0.01). Similar results were obtained in analysis stratified by gender. Conclusions After neoadjuvant therapy for mid-to-low rectal cancer, higher BMI did not compromise sphincter preservation or complete resection or negatively affect long-term outcomes. These findings might be related to the fact that resection was performed in a specialty center with dedicated oncologic surgeons. However, higher BMI was associated with longer operative time, indicating a more technically demanding procedure and longer hospital stay.
Reply Chern, Hueylan, MD; Chou, Joanne, MPH; Donkor, C., MD ...
Journal of the American College of Surgeons,
2010, Letnik:
212, Številka:
1
Journal Article
PDF
