Major determinants of consumer satisfaction with primary care in different health systems.

It is becoming increasingly recognized that patient or 'consumer' views should be taken into account as part of a comprehensive assessment of quality of care. This paper reports a study carried out in four European countries about consumer satisfaction with primary care. The results showed that higher levels of general satisfaction with general practitioner services were found in Canterbury (95%) and Ioannina (87%) than Belgrade (85%) and Moscow (62%). Further analysis of the data showed that in all four cities the key dimensions of satisfaction with general practitioner care are both the nature in quality of the doctor-patient relationship and the GP's professional skills. The implications of these findings are discussed.

Health in the central and eastern countries of the WHO European Region: an overview.

The enormous social, political and economic changes that began in the CCEE/NIS in the late 1980s included the revelation and public discussion of a widening health gap between these countries and the other Member States of the European Region. The continuing economic problems and their effects on health increase the urgency of the need for assistance from the international community. Diverging trends in life expectancy became evident in the mid-1970s, and the gap continued to widen in the 1980s for all major causes of death, particularly cardiovascular diseases. The situation is worse in the NIS than in the CCEE, and worst in the central Asian countries. In 1990, the worst infant mortality rate in these countries was eight times the best rate elsewhere in the Region. Non-mortality data, while patchy, confirm the indications given by mortality data. There is no single reason for the health gap, but contributory factors include the increasing prevalence of major risk factors in lifestyles and the environment, and the low efficiency and effectiveness of health care systems. The current situation and short-term prospects are mixed, but the negative trends in mortality and morbidity patterns are likely to continue for some time. While the worst health problems of the transition period in the CCEE/NIS could largely have been avoided, there is no doubt that economizing on health today will exact large costs tomorrow.

PIP: The socioeconomic conditions in eastern European countries are declining. Deterioration began during the mid-1960s. The mortality gap has continued to widen during the 1980s. The Central Asian Republics show mortality patterns similar to ones in developing countries; infant mortality is about 8 times higher than in western Europe. Infant mortality rates in eastern and central Europe are 2-3 times higher than in western Europe. Cardiovascular diseases are the leading cause of death. Another increasing mortality group is lung cancer, and the gap is widening in the West. The NIS (formerly republics of the Soviet Union) have high rates of communicable diseases preventable through immunization. The logistics of vaccine distribution and storage are inadequate. Abortion is the primary means of family planning. 70% of the population of the Russian Federation reported their health as less than good, and only 20% of Russian military personnel are fit based on international standards. Tobacco consumption and high alcohol consumption are the primary health risks. Poor nutrition, stress, and drug abuse add to the risks. The health gap is wide also due to poor housing conditions and environmental pollution. Health care systems, unhealthy lifestyles, and unhealthy environments all contribute to the widening gap in health. The rigid administrative health structures are not conducive to change. The quality of care is low. Decentralization and private sector involvement may produce needed changes in the quality of health services. CCEE countries spend 4.5-7.1% of gross national product on health, compared to 7.3% in the West. In the Czech Republic, Poland, Hungary, and Slovakia, health expenditures per person are 3-4 times less than in OECD countries. Prices are very high for drugs, food, and energy. Although the medical staff-patient ratio is high, there are shortages in particular specialties. Nurses are poorly trained and in low supply. Hospital equipment is very old and poorly maintained. There is overuse of secondary and tertiary hospitals and underuse of general hospitals.

Using regional indicators: the experience of Europe.

The 1987-1988 health-for-all (HFA) monitoring exercise produced a considerable amount of quantitative and non-quantitative data which were used for the assessment of the progress towards HFA in the European Region. At the same time it demonstrated many shortcomings and problems with regard to the availability and quality of data. Relevance of replies to non-quantitative indicators leaves considerable room for improvements. Good or satisfactory relevance can only be found in about one-third of the country replies. Data on most morbidity indicators, except infectious diseases, were provided on average by one-third of the countries. Nearly two-thirds of the countries provided data on cervical and breast cancer and some occupational diseases. At least half of the data seem not to be comparable; some data are potentially comparable, depending on additional information to be collected. Perceived health estimates are collected by a few countries, but data are not directly comparable. Many countries conduct surveys at different times on one or more aspects of lifestyle. However, comparable data are restricted mainly to educational levels, smoking, alcohol and nutrients. Data on health services and resources are more promising, as they are provided by about two-thirds of the countries.

[Toward health for all in the European region of the WHO. Survey of progress accomplished. II. Preliminary conditions: demographic and health status]. / Vers la santé pour tous dans la région européenne de l'OMS. Surveillance des progrès accomplis. II. Conditions préalables: bilan démographique et sanitaire.

A review of recent progress towards the regional targets set for health for all by the Member States of the European Region of WHO, as regards preliminary conditions for health, and for indicators of mortality, morbidity and disability. Life expectancy, infant and maternal mortality, and mortality from ischaemic heart disease and from traffic accidents show an improvement, as does the incidence of several infectious diseases, but the situation has worsened or stagnated as regards suicide and cancer, and there is a lack of information on disability and chronic morbidity. Despite some progress, the goal of equity in health is still very far from being attained.

[Chief risk factors of ischemic heart disease and mortality of the middle-aged male population of Kaunas]. / Osnovnye faktory riska ishemicheskoi bolezni serdtsa i smertnost' muzhskogo naseleniia srednego vozrasta Kaunasa.

A prospective study, averaging 11 years, of a representative sample of 2455 male residents of Kaunas between 45 and 59 years of age has explored relationships between coronary risk factors and mortality due to coronary heart disease (CHD), cancer, injuries, as well as total mortality rates. An original analytical approach has been developed for the analysis of associations between individual risk factors and mortality that allows to exclude the effects of age and other examined factors. A marked relationship has been demonstrated between: coronary mortality and age, arterial blood pressure, cholesterol, glucose tolerance, smoking, body weight, the presence and clinical form of CHD; cancer-related mortality, and age or smoking; traumatic mortality and smoking; total mortality and age, arterial blood pressure, glucose tolerance, body weight, smoking, and the presence and type of CHD.

[Relation of arterial pressure, blood cholesterol and glucose tolerance to body weight (based on data from a population preventive study)]. / Otsenka zavisimosti arterial'nogo davleniia, soderzhaniia kholesterinav krovi i tolerantnosti k gliukoze ot massy tela (po dannym populiatsionnogo profilakticheskogo issledovaniia).

The relationship of arterial blood pressure and blood levels of cholesterol and glucose (1 hour after a 75 g glucose load) to body weight was assessed. Body weight can be used as an easily-measurable indicator of the efficacy of preventive measures with respect to the above-mentioned coronary risk factors. The data were derived from a study of 6109 males, aged 40-59, carried out within a cooperative multifactorial coronary disease prevention program in Kaunas. The degree of correlation was assessed on the basis of single examinations, and the variation of the levels of the risk factors in question was examined in relation to changes in body weight over a period of time. Quantitative estimates of change in blood pressure and blood cholesterol and glucose levels corresponding to a weight change of 1 kg were obtained.

Prevalence of ischaemic heart disease and of various electrocardiographic changes according to findings of the cooperative Moscow-Kaunas-Minsk study.

In the cooperative study of multifactorial prevention of ischaemic heart disease (IHD), conducted in Moscow, Kaunas and Minsk, the authors investigated and compared the prevalence of IHD, its various forms, ECG changes and the awareness of the IHD patients that they were affected by this disease. Preventive examination of the male population in the 40 to 59 years age group revealed the presence of IHD in 14.8% in Moscow, 10.7% in Kaunas and 14.1% in Minsk. In the male population in Moscow IHD has a more severe course with the prevalence of painful forms, whereas in Kaunas there occur in more than 50% of the patients and in Minsk in 49% painless forms of IHD. Myocardial infarction occurs in Moscow more frequently (3.7%) than in Minsk (3.1%) and in Kaunas (2.5%), and is in Moscow in a higher percentage of cases associated with signs of pronounced cicatricial changes in the myocardium on the ECG. Angina pectoris of effort occurred among persons without MI in Kaunas in 2.4%, in Minsk twice as frequently (4.8%) and in Moscow nearly three times as frequently (6.8%). Of the persons in whom examination established the presence of IHD or angina pectoris of effort, every third in Moscow and every second in Kaunas and Minsk was not aware of their disease.

A lowering of the risk of ischaemic heart disease among the population (according to the results of the Kaunas preventive study).

Out of the total number of 2455 individuals who had passed a primary screening, a group of men aged 45--59 years, with average (borderline) values of arterial pressure (AP), serum cholesterol (CH), and glucose levels after the glucose load, was selected for studies of potential lowering of the level of risk factors of ischaemic heart prevention. The enrollment of the probands lasted 9.4 months on the average (+/- 6.0 months); the preventive double-blind study proper lasted 12 months. The levels of the three specified risk factors sank both during the enrollment period and during the proper 1-year preventive therapy period. The risk factor levels were substantially lowered both in consequence of repetitive regular examinations and by the action of drug treatment (this applies especially to the CH level). In the evaluation of the results of the preventive study, therefore, also the effects of the lowering of the AP and of the CH and glucose levels even to the average values have to be taken into account. The results of the preventive study confirm that it is possible to lower the risk of IHD among the population.

The incidence of arterial hypertension in the male population aged 40-59 years in Moscow and Kaunas.

The authors examined 1480 Moscow and 1568 Kaunas male residents aged between 40 and 59 years. The incidence of arterial hypertension (AH) in Moscow and Kaunas amounted to 27.9 and 21.8% respectively. Of the total number of subjects examined in the two cities 24.5% (Moscow) and 59.4% (Kaunas) were unaware of their condition. Only 12.8% of the Moscow residents and 3.2% of the Kaunas residents were treated. The results are analyzed with respect to earlier therapy, its efficacy and standardization of measurement of arterial pressure in the course of cooperative studies. The high incidence of AH, ignorance of the patients of their condition, the low percentage of patients with an established diagnosis of AH emphasize the need for devising a system of identifying hypertensive patients and for treating them appropriately.

[Experience in conducting a multifactor ischemic heart disease prevention program (data from a cooperative study in Moscow and Kaunas]. / Opyt provedeniia programmy mnogofaktornoi profilaktiki ishemischeskoi bolezni serdtsa (dannye kooperativnogo issledovaniia v Moskve i Kaunase).

A program of multi-factor prevention of ischemic heart disease (IHD) conducted in Moscow and Kaunas is briefly described. Preliminary data on the prevalence of IHD and its risk factors in the two towns are shown and data concerning arterial hypertension are analysed in detail. The preliminary results of measures of primary IHD prevention obtained in the first year of observation are reported. Regular treatment during the first year assisted in increasing the number of patients who were under medical care to 78% in Moscow and to 43% in Kaunas; the number of effectively treated patients increased to 48% in Moscow and to 56% in Kaunas.

[Risk of ischemic heart disease development in 45- to 59-year-old men. The results of a 5-year observation in the Kaunas population study]. / Risk razvitiia ishemicheskoi bolezni serdtsa u 45-59-letnikh muzhchin. Rezul'taty 5-letnego nabliudeniia Kaunasskogo populiatsionnogo issledovaniia.

The possibility of prognosticating the development of ischemic heart disease in persons clinically healthy in respect of this illness was studied. The data on 1,977 males were used, among whom, according to the registers of myocardial infarction and deaths, 34 had suffered from ischemic heart disease in a follow-up period of 5 years. The prognosis was made on the basis of logistic function and the following 6 signs: age, systolic pressure, cholesterol content, smoking, blood sugar level, body mass index. In the upper decile of the assessment of the probability of ischemic heart disease development, 47% of cases with this disease were encountered, i. e. 10% of clinically healthy individuals were distinguished among whom the risk of the development of ischemic heart disease was 8 times that among the remaining persons (0.081 and 0.01, respectively).