Privatization in the health care system of Croatia: effects on general practice accessibility.

This paper analyzes some effects of the privatization process in primary health care in Croatia, and in particular evaluates actions taken by providers to improve their accessibility for patients. The sample was stratified by regional density of practices and the status of practices in relation to privatization. Three groups of general practices were included in the study and were assessed twice (in 1997/1998 and 1999/2000): (1) 106 privatized before the beginning of the study; (2) 96 privatized during the study period and (3) 65 that were not yet privatized. The research was performed by structured interview with general practitioners as informants. The indicators analyzed were: possibilities of obtaining first and follow-up visit appointments, honouring scheduled appointments, scheduling visits by telephone, visiting the practitioner after hours and obtaining telephone advice after working hours. Number of registered patients in the practice and perception of patients' waiting times were also assessed. Privatized practices performed better in improving the accessibility of their services for patients: they increasingly offered the possibility for first and follow-up appointments at precise times, scheduled visits by telephone and provided telephone advice outside working hours. They showed greater intention to honour made appointments in order to lower their patients' waiting times. The study indicates that, in the initial stage of privatization, practitioners tend to extend accessibility by structural improvements that are not time consuming. It seems that providers adjust the level of offered accessibility benefits according to the intensity of market competitiveness. Further research is needed to precisely delineate the range of structural adjustments that could be expected by privatization and to verify the effect of observed changes on the quality of care and health outcomes.

Efficacy of breast shielding during CT of the head.

In light of increasing frequency of CT examinations in the past decades, the aims of this prospective study were to investigate scatter radiation breast exposure in head CT and its dependence upon body constitution, and to assess the efficacy of lead shielding as a means of breast dose reduction. In 49 women referred to head CT for objective medical reasons one breast was covered with lead apron during CT scanning. Radiation doses were measured by use of thermoluminescent dosimeters, at skin of both breasts and over the apron. The doses were then compared as well as correlated to body mass index and meatus acusticus externus-to-dosimeter distance, respectively. Average exposure at the skin of the unshielded breast was 0.28 mGy (range 0.15-0.41 mGy), compared with 0.13 mGy (range 0.05-0.29 mGy) at the shielded breast. The doses showed a mean reduction by 57% due to lead shielding. At least half of breast exposure was imparted to the breast from outside, whereas the remainder results from internal scatter. The higher the body mass index, the higher the percentage of internal scatter in total breast dose. Although the level of scatter radiation to the breast is generally low during head CT examination, the use of lead cover enables recognizable further reduction of the exposure, and is recommended as a feasible and effective procedure of breast protection during CT of the head.

Persistent cervical intersegmental artery and aortic arch coarctation.

A 15-year-old girl presented with upper extremity hypertension and continuous precordial murmur. Arteriography revealed aortic coarctation proximal to the origin of the left subclavian artery. An anomalous artery originated from the aortic arch, between the left common carotid artery and the stenosis. It ascended cranially and filled an angiomatous vascular formation on the left side of the neck. The "angioma" drained into the left subclavian artery. The embryological explanation of the described anomaly is difficult, but probably related to hemodynamic alterations following the prestenotic increase in blood pressure. This may have impaired the obliteration of cervical intersegmental arteries, resulting in the persistence of one of the first three intersegmental arteries as the anomalous branch of the aortic arch. The angiomatous vascular formation in the neck could be the consequence of altered development of anastomoses between the muscular twigs of both vertebral and deep cervical artery. The vessel draining the vascular formation was probably the thyrocervical trunk. Since there were no overt collateral channels or signs of left ventricular hypertrophy by electrocardiography and echocardiography, it seems that the aberrant collateral flow was hemodynamically significant and reduced the afterload on the myocardium. Although the pattern of collateral flow in our case might be considered extremely rare, it is important in preoperative planning and interpretation of imaging studies.

Transformation of health services from civilian to wartime medical corps--example from Bosnia and Herzegovina.

In the multiethnic Bosnia and Herzegovina, Croats and Muslims, attacked by the Yugoslav army and Serbs, had to employ rationally their poorly provisioned civilian health services so that they could respond to the extremely numerous and prompt needs of war conditions. The health services in the areas controlled by Croats and Muslims had to be reorganized twice because of sudden changes of wartime conditions. With further development of the situation, when all three sides participated in the conflict, the number of wounded increased rapidly. In the meantime, a large-scale population shift on an ethnic basis occurred in all parts of Bosnia and Herzegovina, thus giving rise, along with a greater number of the wounded, to a severe humanitarian crisis. Civilians were therefore another heavy burden to the wartime health services. This created enormous problems for the inadequately provisioned health services of Bosnia and Herzegovina in the area under the control of Croats and Muslims. However, poorly equipped with personnel as well as everything else, the health services in the area controlled by Croats and Muslims, through appropriate reorganization, successfully accomplished their task in the wartime medical corps. Besides this correctly executed transformation from civilian health services into a wartime medical corps, high motivation of medical staff also greatly contributed to successful operation of the medical corps in the war zone despite the long duration of the war. In the majority of cases, the wounded were within 30-40 minutes from the moment of injury in the hands of a surgical team and within the next ten minutes were already in the operating theater. After primary wound dressing, the wounded were sent to one of the well-organized main war hospitals for further treatment. This resulted, along with secure evacuation routes, in a minimum number of lifelong invalidity among the wounded.

Breast compression and radiation dose in two different mammographic oblique projections: 45 and 60 degrees.

INTRODUCTION: Standard mammography includes two views, craniocaudal and medio-lateral oblique. Depending on patient's body constitution, central beam angle in mediolateral oblique projection may vary, with 45 degrees being suitable for the majority of patients in routine daily practice. With continuous improvement in X-ray technology and radiographers' training, the risk of radiation induced cancerogenesis is considerably reduced and acceptable when compared to benefit. However, the risk still exists, being cumulative and directly related to absorbed glandular dose. There is no minimal dose of radiation which is absolutely harmless, and every effort to reduce the dose is welcome. In this retrospective study two different angles (45 vs. 60 degrees) of mediolateral oblique view were compared according to radiation dose and efficacy of breast compression. PATIENTS AND METHODS: In 52 women, additional 60 degrees oblique films were done after craniocaudal and mediolateral oblique 45 degrees-films, with the same kVp and positioning technique. Breast thickness, time-current products (mA s) and absorbed doses were compared between 45 degrees- and 60 degrees-films. Subgroups of women with large, small, prominent and pendulous breasts were analyzed separately, following the same methodology as for the whole group. RESULTS: mA s were 11.5% lower and compression 7% better with an angle of 60 degrees than with 45 degrees. In the subgroup of women with small breasts, mA s values were 13% lower and compression 9% better with 60 degrees than with 45 degrees, while in the subgroup with large breasts, mA s were 9% lower and compression 5% better. In the subgroup of patients with pendulous breasts, mA s values were 12% lower and compression 10% better with 60 degrees than with 45 degrees, while in the subgroup with prominent breasts, mA s values were 4% lower and compression 3% better. Absorbed glandular dose was estimated to be approximately 20% lower when an oblique mammogram was done with 60 degrees instead of 45 degrees. The compression with 15 kp was well tolerated by the majority of patients. DISCUSSION AND CONCLUSION: Mammograms of excellent quality should be done with as low a radiation dose as possible. Adequate breast compression is fundamental in mammography due to immobilization of the breast, shortening of the exposure times, reduction of motion and geometric blur and prevention of overpenetration by means of equalizing breast thickness. As the absorbed glandular dose cannot be accurately measured, it is convenient to estimate the dose approximately, on the basis of its linear proportionality with exposure dose. With constant technical properties of X-ray machines, exposure dose is determined only by mA s. Hence, the absorbed glandular dose in our study was influenced only by changes of mA s and breast thickness. As the absorbed dose reduction is proportional to the product of the reduction of mA s and thickness, we estimated that absorbed dose was 7-22% lower if 60 degrees is applied instead of 45 degrees. Breast compression and mA s were more favourable in women with pendulous breasts, possibly because of elongation of the glandular disc in the lateroascending direction, with its longer axis directed more perpendicularly. Fibroglandular tissue in the 60 degrees-view is thus projected onto a larger film area, with less effect of superimposition. In conclusion, because of lower mA s values and better compression, which finally result in a 25% lower absorbed dose, we recommend the oblique view be done with an angle of 60 degrees, especially for small and pendulous breasts.

Treatment of autonomous and toxic thyroid adenomas by percutaneous ultrasound-guided ethanol injection.

PURPOSE: To evaluate the feasibility and efficacy of US-guided percutaneous ethanol injection (PEI) in the treatment of autonomous and toxic thyroid adenomas. MATERIAL AND METHODS: PEI was performed in 42 patients with solitary, scintigraphically "hot" nodules (n=37) or toxic nodular goiter (n=5). The nodular volume ranged from 2.5 to 38 cm3 (mean volume, 20.7+/-14.1 cm3). Ethanol was injected using a free-hand technique, usually in multiple sessions, using color and power Doppler US guidance. Treatment success was evaluated following 3-4 months after PEI by scintigraphy, hormonal status, and US findings. RESULTS: The procedure was technically successful in 39 patients (93%). Three patients were lost to follow-up. Minor complications were pain (all patients), subcutaneous hematoma (n=6), and transitory dysphonia (n=1). A complete cure was achieved in 22 patients (52%), and a partial cure in 10 patients (24%). In 4 cases (9%), the result was unsatisfactory since only moderate hormonal remission was observed. A satisfactory results was thus achieved in 32/42 patients (76%). Significant nodular volume reduction was observed in all cases. Better results were observed in smaller nodules and in cases of autonomous adenomas. There were no cases of recurrent hyperthyreosis. CONCLUSION: US-guided PEI is an efficient and safe method in the treatment of autonomous thyroid nodules and it enables inactivation of nodules with minimal or transitory complications.

Asymptomatic carotid stenosis: selective or routine use of intraluminal shunt.

BACKGROUND: To evaluate the use of temporary intraluminal shunt (IS) during operations in our patients for asymptomatic carotid stenosis (ACS) of the internal carotid artery (ICA). METHODS: Complications of ICA endarterectomy were reviewed in two groups of asymptomatic patients. In group A (144 patients, operation 1972-1985) temporary IS was used in 43 patients with the intraoperatively measured ICA back pressure <50 mmHg. In group B (170 patients, operation 1986-1998) shunt was used in all cases. RESULTS: The incidence of neurologic deficit was higher ia group A than in group B (5.6% vs 1.2%, p<0.05). Within group A, the incidence of neurologic deficit was significantly higher in the subgroup with back pressure >50 mmHg, and thus without shunt, than in group B with routine use of shunt (6.0% vs 1.2%, p<0.05). There were no differences in the incidence of shunt-related complications between the groups (3.0% vs 4.0%, p>0.05). We had no mortality after operations of asymptomatic patients. CONCLUSIONS: The routine use of IS reduced the rate of intraoperative and early postoperative neurologic complications of asymptomatic carotid endarterectomy, and it was not associated with a higher incidence of complications.

Successful closure of large pseudoaneurysm of peroneal artery using transluminal temporary occlusion of the neck with the catheter.

Pseudoaneurysm is well-known complication resulting from surgical or interventional vascular procedures. We present the case of a 51-year-old patient with a large iatrogenic pseudoaneurysm of the peroneal artery, a very rare location. The pseudoaneurysm developed after orthopedic surgery of the knee. Swelling and vascular insufficiency of the calf ensued a few days later. The large peroneal pseudoaneurysm and compression of the anterior and posterior tibial arteries were confirmed by ultrasound and angiography. The pseudoaneurysm was too deep for ultrasound-guided compression or percutaneous obliteration and too large to be occluded by coil embolization alone. Because the pseudoaneurysm failed to occlude even after four coils were introduced into the lumen, pseudoaneurysm thrombosis was achieved by temporary occlusion of its neck with the angiographic catheter. During the occlusion of the neck of the pseudoaneurysm, the patency of the crural arteries and the development of the thrombus in the pseudoaneurysm cavity were monitored with color Doppler ultrasonography. Follow-up examinations after 3 and 6 months showed permanent closure of the pseudoaneurysm and patent crural arteries.

Possible discrepancies between dicentric chromosome frequencies and recorded ionizing radiation doses: in vivo study.

BACKGROUND: The available data on the effects of radiation on humans are limited to the reports of accidental exposure or studies of patients under diagnostic and therapeutic treatment; few reports refer to a occupationally exposed population groups. METHODS: The research was conducted on 66 subjects employed in the Department of Nuclear Medicine and 41 nonemployed controls. For each of them chromosomal analysis and gamma-spectrometer analysis of 24-hour urine were carried out. Exposure doses were measured using film-badge dosimetry. RESULTS: The comparison of dosimetric data obtained by film-badge measurements and the frequency of dicentric chromosomes in each subject revealed no correlation between the two observed parameters. CONCLUSIONS: In view of the above results, the subjects should be studied within job/task groups as they are far more likely to receive comparable doses.

Organization and activity of the health service in the Croatian province of Lika in the first year of the war.

The aim of this report is to present the various aspects of the reorganization of the health service in the Croatian province of Lika during the first year, 1991-1992, of the war in Croatia. In the former Socialist Republic of Yugoslavia, the health service was completely in the hands of the state, and Croatia was not able to transform it in the first year of its independence. The paper documents the personnel, supplies, and equipment that the health service of Lika had at its disposal in the first year of the war, the division of the health service into the stationary and front-line medical corps, and the evacuation protocols developed to transfer surgical patients to the rear-area hospital. The response of the health service allowed for rapid and successful patient treatment, emphasized by the fact that the usual time elapsed between wounding and delivery of the patient to the operating table was less than 30 minutes. All surgeries, with the exception of those involving severe craniocerebral injuries, were performed in the war hospitals of Lika. After stabilization of their postoperative condition, generally within 30 minutes, patients were evacuated to the rear-area hospital in Rijeka, with artificial respiration. The distance by road from the war hospitals in Otocac and Gospic to the reararea hospital in Rijeka was 120 and 170 km, respectively. Collectively, the results of our work demonstrate that a nonmilitary health service can be transformed successfully and efficiently into a war medical service. Yet, we believe that this is possible only under the extreme conditions of a defensive war.

[The age of diagnostic radiologic equipment in Croatia]. / Starost radioloske dijagnosticke opreme u Republici Hrvatskoj.

The quality of health care also depends partly on technological equipment. Among the devices which diminish the quality of services if they are old, increasing at the same time the danger when used, are certainly those in radiodiagnostics. Besides, their age controls the dose of radiation to which patients and professional staff are exposed. The knowledge of the age of this equipment is the basis of the plans for further development. The aim of the study is to determine the age of each individual radiodiagnostic device in Croatian institutions. The assessment of each device was made by a qualified professional. The method of data collection was based on the uniform questionnaire which comprised radiodiagnostic devices older than ten years, classified according to type and location (primary health care center or hospital, in total 655 devices). Determination of the age index of generators and x-ray tubes older than seven years (according to the World Bank recommendation), included also mobile units (55 for fluoroscopy and 68 for radiography), devices for dental radiography, devices in private sector (118) and devices which are out of use but not officially blocked (88), which means in total 859 generators and 1111 x-ray tubes. In addition, the availability of image intensifiers for fluoroscopy and manufactures of all devices were determined. The results of the study reveal that in primary health care centers, out of 248 radiodiagnostic devices, 193 are older than ten years (77.8%), while 4 are of unknown age. In hospitals, out of 407 devices, there are 261 older than ten years (64.1%), while 46 are of unknown age (11.3%). Among devices for fluoroscopy, 97 out of totally 206 have no image intensifier (32%). These devices should be immediately excluded from utilization. The index of age above seven years, which is according to the recommendation of the World Bank the lifetime of devices, reveals that 859 generators out of totally 984 (91%) are too old to be used, while there are 1111 x-ray tubes out of totally 1206 (92%) which are in the same condition. Regarding the manufacturers, the ratio is also unfavourable, since 49.3% of devices have been manufactured by comparies whose technology and spare parts are now inaccessible (Elektronska industrija). Such unacceptable obsoleteness of the radiological equipment requires urgent renewal.

[Diagnostic approach in patients with kidney tumors]. / Racionalizacija dijagnostickih postupaka u bolesnika s tumorima bubrega.

The basic reason for the rationalization of diagnostic procedure is the cost benefit relation and making of the diagnostic course algorithms. On the basis of the Receiver Operating Characteristic (ROC) analysis of the diagnostic procedure (excretory urography, ultrasonography, computed tomography, digital subtraction angiography) the significance ranking has been established for certain kidney tumor diagnostic procedures. Angiography has been determined to be the most precise method, but the high degree of sensitivity (98%) and accurate diagnosis probability (98%), as well as noninvasiveness and relative inexpensiveness of ultrasonographic examination procedure, all argue for ultrasonography as the cornerstone, of renal tumor diagnosis. Using conditional probabilities and the Bayes analysis the advantage of the newly suggested over the standard diagnostic course has been calculated. The study has shown a significant decrease in the number of examinations: in 60 patients 16 excretory urographies, 10 computed tomographies, and 22 digital subtraction angiographies can be spared.

Renal vascular resistance in diabetic nephropathy: duplex Doppler US evaluation.

PURPOSE: To evaluate duplex Doppler sonography to assess renal vascular resistance (RVR) in diabetic patients. MATERIALS AND METHODS: Resistive indexes (RIs) and pulsatility indexes (PIs) were measured in intrarenal arteries of 144 patients with diabetes mellitus and 61 control subjects. RIs and PIs were compared for control subjects and patients with diabetic nephropathy and correlated with laboratory and clinical findings. RESULTS: In control subjects, the mean RI was 0.595 +/- 0.033 (standard deviation) and mean PI was 1.001 +/- 0.105. Elevated RIs and PIs accompanied progression of nephropathy. Statistically significant (P < .001) correlations were observed between both RI and PI and serum creatinine level, creatinine clearance rate, systolic and diastolic blood pressure measurements, and patient age. CONCLUSION: Doppler indexes reflect increased RVR in diabetic nephropathy and correlate with laboratory and clinical parameters, but RI and PI measurements offer no advantages over these parameters to predict disease progress or in patient care.

Intrarenal duplex Doppler sonographic evaluation of unilateral native kidney obstruction.

RIs were measured in intrarenal arteries in 66 kidneys of 33 examinees without renal impairment and in 42 kidneys of 21 patients with unilateral urinary obstruction. The mean RI in normal kidneys was 0.593 +/- 0.040. Patients with unilateral obstruction had a mean RI of 0.709 +/- 0.039 in obstructed kidneys and a mean RI of 0.591 +/- 0.033 in contralateral nonobstructed kidneys. Statistically significant differences have been noticed in the groups of normal versus obstructed kidneys (P < 0.001) and of obstructed versus contralateral nonobstructed kidneys (P < 0.001). The mean dRI was 0.118 +/- 0.034 in patients with unilateral obstruction, and it was 0.014 +/- 0.012 in examinees without renal impairment (P < 0.001). A comparison of RI values between the right and left kidneys in a patient with unilateral obstruction proved more useful than using a 0.7 RI cutoff value in a Doppler sonographic diagnosis of unilateral obstruction.

[The integral civil and military health care system]. / Integralni civilni i vojni zdravstveni sustav.

The problem of the organization of the army health care system in the Republic of Croatia is very actual. At the beginning of the war, the all fighting formations were covered by the civil health organization. After the Croatian army was organized, the differentiation between civil and army health system has been established. The characteristic of that differentiation was integral system with primary health care and transporting of the wounded persons organized by the army, while the specialistic and hospital care were organized by the civil institutions. In the peaceful future the integral health system must be kept. There is no need for the army hospitals, because only one hundred beds for a year will be enough for the army consisted of about 50,000 persons. The civil hospitals can provide the high quality service with a short-term transporting of the patients. The Government of the Republic of Croatia has decided to establish such integral system which includes the civil hospital care and the civil specialistic out-patient care, while the primary and specific health care are in the organization of the army. This system is less expensive than the full army health system, but is of better quality and includes an easy approach to all health institutions.

[The direction of Croatian health care in the post-war period]. / Smjernice hrvatskoga zdravstva u poslijeratnom razdoblju.

A radical transformation of the health-care system in Croatia has begun after the first free and democratic elections in the country. Changes were initiated along the lines suggested by the World Health Organization experts and in accordance with the positive experiences of the earlier health-care organization and practice. The newly introduced changes involved the introduction of market mechanisms in health care (private medical practice and contracting for medical services), establishment of health insurance funds, formulation of rules and standards for the provision of medical services, and reorganization of management in medical institutions. With the start of the armed aggression against the Republic of Croatia, all of these activities ceased and the health-care system switched very quickly from peace-time to war-time operation. At the same time, preparatory work continued on the definitive reorganization of the health-care and health insurance systems. The present paper discusses the underlying principles for the three basic pieces of legislation: Health Care Act, Professional Chambers Act, and Health Insurance Act. The Health Care Act will be based on new patterns of property relations in health-care organizations. Three types of ownership are envisaged - state, private and mixed. Most of the existing health-care institutions will be state-owned, and the owner (government, district or municipal authority) will appoint a governing board in each case, which, in turn, will appoint the director or manager. A separate piece of legislation will regulate the status of health workers.(ABSTRACT TRUNCATED AT 250 WORDS)