ObjectivesCancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. ...However, evidence to explain how different national health systems influence primary care practitioners’ (PCPs’) referral decisions is lacking.This study analyses health system factors potentially influencing PCPs’ referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.DesignBased on a content-validity consensus, a list of 45 items relating to a PCP’s decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs’ referral decision-making.SettingA primary care study; 25 participating centres in 20 European countries.Participants1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.Outcome measuresThe factors derived from items related to PCPs’ referral decision-making. Mean factor scores were produced for each country, allowing comparisons.ResultsFactor analysis identified five underlying factors: PCPs’ ability to refer; degree of direct patient access to secondary care; PCPs’ perceptions of being under pressure; expectations of PCPs’ role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.ConclusionsFive healthcare system factors influencing PCPs’ referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.
Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners' (PCPs') clinical ...decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania).
PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer.
The survey was completed by 475 PCPs. There were significant national differences in PCPs' direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs' country had a significant effect on their likelihood of investigating or referring the patient.
There are large differences between Balkan region countries in PCPs' levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.
Svjetska zdravstvena organizacija, posebno koordinirajuće tijelo međunarodnog javnog zdravstva Ujedinjenih naroda, ima izniman značaj u razvoju i unaprjeđenju javnog zdravstva na globalnoj razini te ...ove godine slavi 75 godina svog postojanja. Jedan od njezinih suosnivača i prvi predsjednik bio je Andrija Štampar. On je postavio deset glavnih postulata koji su i danas izrazito relevantni u kontekstu modernog javnozdravstvenog djelovanja. Do danas, Svjetska zdravstvena organizacija postigla je iznimne uspjehe na globalnoj razini, od usko usmjerenih, poput eradikacije velikih boginja, do sveobuhvatnijih, poput uvođenja Integrirane strategije vođenja dječjih bolesti. Donosimo pregled postignuća Andrije Štampara i Svjetske zdravstvene organizacije uz njihove današnje odjeke.
The World Health Organization, a special United Nations public health coordinatig body h a vital role in global public health development and improvement is celebrating its 75th anniversary. One of its founders and its first president was Andrija Štampar who created its 10 main postulates that are still extremely relevant. Until today, the World Health Organization has achieved extraordinary global feats, from narrowly focused ones, such as smallpox eradication, to wider-aiming ones, such as the implementation of the Integrated Management of Childhood Illness strategy. We review the achievements and modern ripples of Andrija Štampar and the World Health Organization.
Objective: European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study ...explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.
Design: Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.
Setting: A total of 14 countries.
Subjects: Consensus groups of PCPs.
Main outcome measures: Probability of initial presentation to a PCP for four clinical vignettes.
Results: There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r = −0.16, 95% CI −0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = −0.57, 95% CI −0.83 to −0.12; ovary: r = −0.13, 95% CI −0.57 to 0.38; breast r = 0.14, 95% CI −0.36 to 0.58; bowel: r = 0.20, 95% CI −0.31 to 0.62).
Conclusions: There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival.
KEY POINTS
European cancer survival rates vary widely, and health system factors may account for some of these differences.
The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP.
The degree to which PCPs act as gatekeepers varies considerably from country to country.
There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.
Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different ...healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries.
A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated.
Centres in 20 European countries with widely varying cancer survival rates.
A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country.
PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers.
When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.
While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward ...referral.
To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis.
A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer.
Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data.
A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately.
The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.
This paper analyses the current situation in the Croatian health-care system, with special emphasis on the (dis)organization of palliative care within the public health, more precisely gerontology ...context. Namely, population world-wide is getting older, that is both a statistical and an everyday-medical fact. Today we consider citizens after the age of 65 as the elderly, with a tendency to move the age-limit to 75 years. Croatia on the matter swiftly follows global trends, while literature points to the fact that an increase in the elderly population dictates the need for an organized system of palliative care and hospice building. Although we cannot ignore the fact that children can become palliative care patients, we can conclude that these are predominantly elderly patients. In fact, approximately half of patients--users of palliative care--have some type of oncological diagnosis; a significant number of patients suffer from dementia, stroke, or heart failure. As for the Primorsko-goranska county and the City of Rijeka, they show similar trend, as can be illustrated with data from the 2011 census, when the share of citizens over 65 years in the population of the Primorsko-goranska county reached 18.91%, and in the population of the City of Rijeka 19.74%. Thus, one of the main quality-of-life issues in the Croatian senior population is the (dis)function of the palliative medicine/care system. Practice, namely, shows that there has still been no implementation. In particular, palliative medicine is not yet recognized as a speciality or sub-speciality, standards and norms for this activity are not set, palliative care is still not included in the system of obligatory health insurance, and as far as the national strategy of health policy for the area of palliative care, Croatian Government at its meeting held on 27th December 2013 finally adopted the "Strategic Plan for Palliative Care of the Republic of Croatia for the period from 2014 to 2016". Exactly because we are a decade behind European standards (Recommendation Rec (2003) 24 of the Committee of Ministers to member states on the organization of palliative care), it is more than legitimate to place this subject at the centre of the current Croatian gerontology interest.
ObjectiveThe overall objective of this study was to examine the differences in ultrasound availability in primary care across Europe.DesignCross-sectional study.SettingPrimary ...care.ParticipantsPrimary care physicians (PCPs).Primary and secondary outcomes measuresThe primary aim was to describe the variation in in-house primary care ultrasonography availability across Europe using descriptive statistics. The secondary aim was to explore associations between in-house ultrasonography availability and the characteristics of PCPs and their clinics using a mixed-effects logistic regression model.ResultsWe collected data from 20 European countries. A total of 2086 PCPs participated, varying from 59 to 446 PCPs per country. The median response rate per country was 24.8%. The median (minimum–maximum) percentage of PCPs across Europe with access to in-house abdominal ultrasonography was 15.3% (0.0%–98.1%) and 12.1% (0.0%–30.8%) had access to in-house pelvic ultrasonography with large variations between countries. We found associations between in-house abdominal ultrasonography availability and larger clinics (OR 2.5, 95% CI 1.2 to 4.9) and clinics with medical doctors specialised in areas, which traditionally use ultrasonography (OR 2.1, 95% CI 1.1 to 3.8). Corresponding associations were found between in-house pelvic ultrasonography availability and larger clinics (OR 1.9, 95% CI 1.3 to 2.7) and clinics with medical doctors specialised in areas, which traditionally use ultrasonography (OR 3.0, 95% CI 1.8 to 5.1). Additionally, we found a negative association between urban clinics and in-house pelvic ultrasound availability (OR 0.5, 95% CI 0.2 to 0.9).ConclusionsAcross Europe, there is a large variation in PCPs’ access to in-house ultrasonography and organisational aspects of primary care seem to determine this variation. If evidence continues to support ultrasonography as a front-line point-of-care test, implementation strategies for increasing its availability in primary care are needed. Future research should focus on facilitators and barriers that may affect the implementation process.
Cervical cancer is the most common cancer in women, the second most frequent malignancy in women and the second most common cause of death in women suffering from cancer worldwide. In 2009, in the ...Primorje-Goranska County 52 (4.1%) women were hospitalized for the treatment of cervical cancer.
The aim of this paper is to show the methodology and results of the County program in 2009.
The County Institute of Public Health (IPH) has been conducting this screening program systematically since 2006. In 2009, screening was conducted at six gynecologic practices with coverage of 6000 women. Prior to Program performance, the IPH provide the gynecologists with all necessary logistics (brushes for cytobrush technique, Pap tests, addressed envelopes, invitation letters and patient questionnaires). The gynecologists include women by random choice, each gynecologist around 1000 women of the specified age group. They send invitations to women with specified date and time of testing. Swabs are referred to the Cytology Laboratory, Rijeka University Hospital Center in Rijeka. For the purpose of this Program, IPH has designed a questionnaire for women, containing 13 questions. Patients give the questionnaires back to the gynecologists, who send them to the IPH for statistical analysis. Data collected from the questionnaires and Pap test findings are entered in a specially designed computer program. During Program implementation, the IPH, gynecologists and cytologists work together to improve the quality of testing. For the purpose of education of women about sexual health and to improving the response rate, IPH has created and distributed 10,000 educational brochures entitled Sexual health of women, the knowledge is power.
In 2009, the response rate in the Program was 41.9% (n=2514). Cytologic analysis of Pap tests yielded 94.5% of negative results and 5.1% of abnormal findings. Adequacy of 99.6% of Pap smears was satisfactory, while 0.4% of samples were of poor quality that could not be analyzed. Results showed 66.7% of women to undergo gynecologic examination once a year, whereas 17.9% of women had not been for gynecologic examination for more than 3 years. The majority (90.7%) of women that participated in the Program were visiting the chosen gynecologist at primary health care.
Throughout the Program implementation, the leading problem continued to be low turnout of gynecologists for inclusion in the Program and poor turnout of invited women. The cause of this problem lies in the insufficient number of gynecologic teams and too many women in care of one gynecologist. This problem points to the need of restructuring of primary health care for women with emphasis on the number of health professionals. Results of the analysis of two questions in the questionnaire indicated inadequate knowledge of women about the importance of regular gynecologic control. When planning screening program in the coming years, attention should be focused on the motivation of women of younger age groups as well as those that are irregularly controlled.
Organized screening can reduce the risk and mortality of cervical cancer. It is also known that with a relatively small investment but with better health care organization, the response of women can increase. Taking into account the threat posed by cervical cancer for women's health and social burden, the need of prevention strategies, primarily screening tests, is clear as a means for early detection of the problem and timely removal of abnormal cells.
Prvi broj Narodnog zdravstvenog lista, u izdanju Zavoda za zaštitu zdravlja, izašao je iz tiska 7. travnja 1958. godine, na Dan zdravlja, kao mjesečnik za zdravstveno prosvjećivanje. Na stranicama ...velikoga novinskog formata razmatrao je široku zdravstvenu problematiku radi informiranja i poučavanja svojih čitatelja. Suradnici su bili pretežno zdravstveni radnici: liječnici, zdravstveni tehničari, medicinske sestre, ali i prosvjetni radnici, psiholozi i drugi. Tematika je bila usmjerena na preventivne mjere radi kolektivne zaštite narodnog i individualnog zdravlja.S godinama izlaženja sadržaj lista se mijenjao u skladu s napretkom struke i novinama u zdravstvu. Pisalo se o zaraznim bolestima koje su tada bile vodeći javnozdravstveni problem, o razvoju zdravstvene službe, otvaranju novih zdravstvenih objekata, počecima uporabe ultrazvuka i lasera u medicini. Aktualnost je bila odlika lista od početka njegova izlaženja. članci su uvijek bili primjereni vremenu i razvoju zdravstva i medicinske znanosti.
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