Abstract Background China is reshaping its health-care system to orient towards primary care. We developed a short instrument on the basis of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) ...to assess patients' experiences of primary-care delivery in community health centres, the major primary-care provider in urban areas. Methods A multistage cluster sampling method was used to select seven geographical regions in southern China where the population's ageing and gender structure is similar to that of China's overall population. A validated PCAT-AE (Mandarin Chinese short version) with 33 PCAT items on a four-point Likert-type scale was used, with higher scores representing better primary-care experiences. This study was approved by the Ethics Committee of Guangzhou Medical University, Guangzhou, China, and the Survey and Behaviour Research Ethics Committee of The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (TB106179/MD10606). All study participants provided written consent. Findings The overall response rate of adult subjects interviewed at community health centres was 85·8% (3360 of 3916). Both frequent (2237) and less-frequent service users (1123) were surveyed, among which 1122 (33%) patients had an optimum PCAT score (higher than the third quantile of the score range—ie, above 99 of 132). The proportion of subjects with optimum scores in individual primary-care domains ranged from 62·1% (95%CI 59·8–64·3) in the comprehensiveness of service attribute to only 16·6% (14·7–18·7) in the community orientation attribute. Among all subjects, those with social medical insurance were more likely to report optimum primary care experience (adjusted odds ratio 2·30, 95% CI 1·92–2·75) than those uninsured. In the stratified analysis among subjects who were uninsured, those attending community health centres owned and managed by the government as their usual source of primary care had the highest PCAT scores compared with other models of community health centres owned and managed by secondary or tertiary hospitals (95·16 vs 90·18; p=0·0001) or by private investors (95·16 vs 87·80; p<0·0001), as a result of better first-contact care and coordination of care. Interpretation The study suggests an urgent need to understand and address how social medical insurance coverage could affect patients' experiences. The community health centre model with a government-dominant top-down approach seems to be most effective in solving conundrums for China's health-care reform. Funding This study was funded by the Bauhinia Foundation Research Centre; Department of Health, Guangdong province (C2009006/2009–2013); Department of Education, Guangdong province (BKZZ2011047/2010–2013); Medical Research Fund, Chinese Medical Association (2010-08-05); and Community Health Research Fund, Community Health Association of China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong–Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong and the Scottish Government (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions—General Practice Exploratory Teaching Centre (GDJG-2010-N38-35, Guangdong Department of Education) and The Ninth Round of Guangdong Key Disciplines—General Practice (GDJY-2012-N13-85, Guangdong Department of Education), both of which he leads.
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 Associations of multimorbidity and income with hospital admission were investigated in population samples from 3 widely differing health care systems: Scotland (n = 36,921), China (n = ...162,464), and Hong Kong (n = 29,187). Multimorbidity increased odds of admissions in all 3 settings. In Scotland, poorer people were more likely to be admitted (adjusted odds ratio aOR = 1.62; 95% CI, 1.41-1.86 for the lowest income group vs the highest), whereas China showed the opposite (aOR = 0.58; 95% CI, 0.56-0.60). In Hong Kong, poorer people were more likely to be admitted to public hospitals (aOR = 1.68; 95% CI, 1.36-2.07), but less likely to be admitted to private ones (aOR = 0.18; 95% CI, 0.13-0.25). Strategies to improve equitable health care should consider the impact of socioeconomic deprivation on the use of health care resources, particularly among populations with prevalent multimorbidity.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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 Twenty-five percent of patients with colorectal cancer present with simultaneous liver metastasis. Complete resection is the only potential curative treatment. Due to improvements in ...operative and perioperative management, simultaneous liver and colon resections are an accepted procedure at specialized centers for selected patients. Nevertheless, little is known about the long-term, oncologic results of simultaneous operative procedures compared with those of staged operations. Methods Patients with colorectal cancer and simultaneous liver metastases presenting for complete resection at a tertiary cancer center were identified. Patients who received the primary colon resection at an outside institution were excluded from analysis. Results Between 1984 and 2008, 429 patients underwent operative treatment for colorectal cancer with simultaneous liver metastasis. Of these, 320 (75%) had simultaneous resection and 109 had staged resection. There was no difference in the distribution of primary tumor locations between the 2 groups. Mean size of the hepatic metastases was significantly greater in the staged group (median 4 cm vs 2.5 cm; P < .01). Neither disease-free nor overall survival differed significantly between the 2 treatment strategies. The extent of the liver procedure (more than 3 segments) was identified as a risk factor for decreased disease-free and overall survival (both P < .01). Conclusion Simultaneous liver and colorectal resections for metastatic colorectal cancer are associated with similar long-term cancer outcome compared with staged procedures.
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 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.
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.
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.
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.
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