Changes in Total Knee Arthroplasty Utilization since the Implementation of ACA: An Analysis of Patient-Hospital Demographics, Costs, and Charges.

The Patient Protection and Affordable Care Act (PPACA) formed the Center for Medicare and Medicaid Innovation Center which has implemented experimental reimbursement models targeted at high-demand procedures to improve care quality. However, the effect of health care reform on total knee arthroplasty (TKA) procedures has not been explored. This study explores patient-hospital level demographics, inpatient costs, and charges related to TKA procedures between 2009 and 2015. The National Inpatient Sample database was utilized to identify patients who received primary TKA between January 2009 and October 2015 (4,283,387 cases). Categorical, continuous, and ordinal data were analyzed using chi-square/Fisher's exact test, t-test/analysis of variance, or Kruskal-Wallis' test, respectively. There was an increase in proportion of TKA recipients belonging to minority groups and the lowest quartile of median income (p < 0.05). There was a 1.9% increase in recipients using Medicaid as a primary payor and volume shifts from urban nonteaching toward urban teaching hospitals. There was a reduction in mean length of stay and mean inpatient costs. There were increases in hospital charges, but reductions in rates of inpatient mortality, and other postoperative complications. TKA procedures remain the most common surgical procedure; therefore, our study assessed national trends to capture the effect of PPACA. We found an increasing proportion of TKA recipients belonging to minority and low-income groups, volume shifts to urban teaching hospitals, and lower costs of care. These findings may be useful in objectively critiquing the effects of PPACA on TKA-related care.

[Antidepressants, anxiolytics and hypnotics prescribed to young adults before and after an economic crisis in Iceland - A cross-sectional study at the Primary Health Care of Reykjavik capital area].

BACKGROUND: According to research findings, the financial crisis hitting Iceland in the autumn of 2008 caused both economic and health-related effects on the Icelandic population. It has been well known that the Icelandic population uses more antidepressants, anxiolytics and hypnotics compared to other Nordic countries. The aim of this research was to study the trend in prescription for these drugs by the Primary Health Care of Reykjavik capital area to young adults, during the years prior to and following the crisis. METHOD: In this cross-sectional study, data were gathered on all medical prescriptions of antidepressants, anxiolytics and hypnotics, prescribed by the Primary Health Care of Reykjavik capital area to people aged 18-35, during 2006-2016. While Reykjavík capital residents in the specified age group were approximately 55 thousand during the research period, this study included data on approximately 23 thousand individuals, received from the Icelandic electronical medical record system "Saga" used by the Primary Health Care. RESULTS: Research results demonstrate a significant average annual increase of prescribed defined daily doses (DDD) for all three medication categories during the research period; 3% (p<0,001) for anxiolytics, 1.6% (p<0,001) for hypnotics and 10.5% (p<0,001) for antidepressants. Between 2008-2009, prescribed daily doses of anxiolytics increased by 22.7% (p<0,001), where a 12.9% (p<0,001) increase was seen for women and 39.5% (p<0,001) increase for men. Of those men who were prescribed anxiolytics in 2009, 35% had no history of such prescriptions the previous year. From 2006-2008 an average annual increase of 13.6% (p<0,001) was seen in prescribed daily doses of hypnotics, whereof 24.4% (p<0,001) increase was seen for men and 7.8% (p<0,001) for women. CONCLUSIONS: This study demonstrates a significant increase in prescribed amount of hypnotics and anxiolytics during the years prior and after the economic crisis, with more prominent results amongst men compared to women. This trend was however not observed for antidepressants, which could suggest an overall tendency towards short- and fast acting drug prescriptions as a treatment for challenging difficult personal circumstances during the economic crisis in Iceland.

Declining Endoscopic Care by Family Physicians in Both Rural and Urban Areas.

Using data from 2014 through 2016, we demonstrated a decline in the percentage of family physicians providing endoscopic services in both rural and urban areas. Our findings suggest that forces in the health care system may be influencing the reduction in scope, rather than specific geographic factors.

Increase in Contraceptive Counseling by Primary Care Clinicians After Implementation of One Key Question® at an Urban Community Health Center.

Introduction To provide quality family planning services and reduce racial and socioeconomic disparities in unintended pregnancy and pregnancy outcomes, primary care clinicians should routinely assess women's reproductive health needs and provide patient-centered contraceptive and preconception counseling. One Key Question® asks women if they would like to become pregnant in the next year and prompts clinicians to provide counseling appropriate to each patient. We conducted a pilot study to assess if implementing One Key Question® in the Electronic Medical Record (EMR) of an urban community health center, coupled with brief clinician training, would increase rates of contraceptive and preconception counseling. Methods We incorporated One Key Question® into a new EMR form and provided a brief training to primary care clinicians on reproductive life plan assessment, preconception counseling, and contraception. We surveyed women patients, ages 18-49, after their visit and compared pre- vsersus post-intervention rates of patient-reported contraceptive and preconception counseling. Results After One Key Question® was introduced in the clinic EMR and clinicians underwent brief training on its use, patients reported significantly higher rates of their clinician counseling them about contraception (52% vs. 76%, p = 0.040) and recommending a long-acting reversible contraceptive (LARC) method (10% vs. 32%, p = 0.035). There were no significant changes in preconception counseling. Discussion After EMR integration of One Key Question® coupled with brief clinician training, rates of contraceptive counseling and LARC recommendations increased in this community health center pilot study. Future research should compare One Key Question® to standard care in a prospective randomized trial.

Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide.

BACKGROUND AND AIMS: The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers. METHODS: We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost. RESULTS: We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients. CONCLUSIONS: In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.

Future projection of the physician workforce and its geographical equity in Japan: a cohort-component model.

INTRODUCTION: The geographical inequity of physicians is a serious problem in Japan. However, there is little evidence of inequity in the future geographical distribution of physicians, even though the future physician supply at the national level has been estimated. In addition, possible changes in the age and sex distribution of future physicians are unclear. Thus, the purpose of this study is to project the future geographical distribution of physicians and their demographics. METHODS: We used a cohort-component model with the following assumptions: basic population, future mortality rate, future new registration rate, and future in-migration and out-migration rates. We examined changes in the number of physicians from 2005 to 2035 in secondary medical areas (SMAs) in Japan. To clarify the trends by regional characteristics, SMAs were divided into four groups based on urban or rural status and initial physician supply (lower/higher). The number of physicians was calculated separately by sex and age strata. RESULTS: From 2005 to 2035, the absolute number of physicians aged 25-64 will decline by 6.1% in rural areas with an initially lower physician supply, but it will increase by 37.0% in urban areas with an initially lower supply. The proportion of aged physicians will increase in all areas, especially in rural ones with an initially lower supply, where it will change from 14.4% to 31.3%. The inequity in the geographical distribution of physicians will expand despite an increase in the number of physicians in rural areas. CONCLUSIONS: We found that the geographical disparity of physicians will worsen from 2005 to 2035. Furthermore, physicians aged 25-64 will be more concentrated in urban areas, and physicians will age more rapidly in rural places than urban ones. The regional disparity in the physician supply will worsen in the future if new and drastic measures are not taken.

[Inequality in access to health services between urban and rural areas in Brazil: a disaggregation of factors from 1998 to 2008]. / Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008.

Access to healthcare is an important dimension of inequalities between urban and rural areas. Access is lower in rural areas due to the population's greater social vulnerability and greater difficulties in access among its social groups. Based on data from the health supplement of the Brazilian National Household Sample Survey, we analyzed the determinants of access and differences between urban and rural areas from 1998 to 2008. The analysis of determinants of access to health services used binary logistic regression. Differences between urban and rural areas were disaggregated as observable factors (enabling, need, and predisposing) and non-observable factors (supply and difficulty in access). The results highlight that inequality in access is higher in rural areas. Need factors are fundamental determinants of access to health, while enabling factor are more important for explaining the differences between urban and rural areas. The slight reduction in differences during the period was due mainly to changes in the rural population's composition.

O acesso à saúde é uma importante dimensão das desigualdades entre áreas urbanas e rurais. O acesso é menor nas áreas rurais em função da maior vulnerabilidade social de sua população e das maiores dificuldades de acesso que seus grupos sociais estão submetidos. A partir de dados do suplemento de saúde da Pesquisa Nacional por Amostra de Domicílios, foram analisados os determinantes do acesso e das diferenças entre áreas urbanas e rurais nos anos de 1998 a 2008. A análise dos determinantes do acesso aos serviços de saúde foi realizada pelo modelo de regressão logística binária. As diferenças entre áreas urbanas e rurais foram decompostas em fatores observáveis (fatores de capacitação, necessidade e predisposição) e não observáveis (oferta e dificuldade de acesso). Os resultados destacam que a desigualdade de acesso é elevada e maior nas áreas rurais. Os fatores de necessidade são determinantes fundamentais do acesso à saúde, enquanto que os fatores de capacitação são mais importantes para explicar as diferenças entre as áreas urbanas e rurais. A tênue redução das diferenças no período se deveu fundamentalmente a mudanças na composição da população rural.

El acceso a la salud es una importante dimensión de las desigualdades entre áreas urbanas y rurales. El acceso es menor en las áreas rurales, en función de una mayor vulnerabilidad social de su población y de las mayores dificultades de acceso a la que están sometidos sus grupos sociales. A partir de los datos del suplemento de salud de la Encuesta Nacional por Muestra de Domicilios, se analizaron los determinantes de acceso y diferencias entre áreas urbanas y rurales, desde el año 1998 a 2008. El análisis de los determinantes de acceso a los servicios de salud se realizó mediante un modelo de regresión logística binaria. Las diferencias entre áreas urbanas y rurales se dividieron en factores observables (factores de capacitación, necesidad y predisposición) y no observables (oferta y dificultad de acceso). Los resultados destacan que la desigualdad de acceso es elevada y superior en las áreas rurales. Los factores de necesidad son determinantes fundamentales del acceso a la salud, mientras que los factores de capacitación son más importantes para explicar las diferencias entre áreas urbanas y rurales. La tenue reducción de las diferencias en el período se debió fundamentalmente a cambios en la composición de la población rural.

Reducing the medical economic burden of health insurance in China: Achievements and challenges.

The aims of this study were to describe health insurance reforms initiated by the Chinese government over the past two decades, to review their achievements in reducing the medical economic burden, and to summarize the challenges that still exist regarding a further reduction in out-of-pocket expenditures in this country. China has successfully attained the goal of providing health insurance coverage to almost the entire population by developing a mixed health insurance system, which consists of Urban Employees Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NCMS), and supplementary Catastrophic Health Insurance. Despite this achievement, China is still facing the challenges of a disparity in the medical economic burden by region and by health insurance scheme, relatively little protection from financial risk compared to developed countries, as well as low efficiency and quality of care under current payment systems. To further reduce the disparity in the medical economic burden and to increase the overall protection from financial risk in China, the Government should increase central government transfers to NCMS and URBMI enrollees in poor regions and increase the total amount of government subsidies to NCMS. In addition, China should improve the efficiency and quality of health insurance by further reforming the payment system.

Effective coverage of essential inpatient care for small and sick newborns in a high mortality urban setting: a cross-sectional study in Nairobi City County, Kenya.

BACKGROUND: Effective coverage requires that those in need can access skilled care supported by adequate resources. There are, however, few studies of effective coverage of facility-based neonatal care in low-income settings, despite the recognition that improving newborn survival is a global priority. METHODS: We used a detailed retrospective review of medical records for neonatal admissions to public, private not-for-profit (mission) and private-for-profit (private) sector facilities providing 24×7 inpatient neonatal care in Nairobi City County to estimate the proportion of small and sick newborns receiving nationally recommended care across six process domains. We used our findings to explore the relationship between facility measures of structure and process and estimate effective coverage. RESULTS: Of 33 eligible facilities, 28 (four public, six mission and 18 private), providing an estimated 98.7% of inpatient neonatal care in the county, agreed to partake. Data from 1184 admission episodes were collected. Overall performance was lowest (weighted mean score 0.35 [95% confidence interval or CI: 0.22-0.48] out of 1) for correct prescription of fluid and feed volumes and best (0.86 [95% CI: 0.80-0.93]) for documentation of demographic characteristics. Doses of gentamicin, when prescribed, were at least 20% higher than recommended in 11.7% cases. Larger (often public) facilities tended to have higher process and structural quality scores compared with smaller, predominantly private, facilities. We estimate effective coverage to be 25% (estimate range: 21-31%). These newborns received high-quality inpatient care, while almost half (44.5%) of newborns needed care but did not receive it and a further 30.4% of newborns received an inadequate service. CONCLUSIONS: Failure to receive services and gaps in quality of care both contribute to a shortfall in effective coverage in Nairobi City County. Three-quarters of small and sick newborns do not have access to high-quality facility-based care. Substantial improvements in effective coverage will be required to tackle high neonatal mortality in this urban setting with high levels of poverty.

The Intersection of National Immigration and Healthcare Policy.

Immigration policy and health care policy remain principal undertakings of the federal government. The two have recently been pursued independently in the judicial and legislative arenas. Unbeknownst to many policymakers, however, national immigration policy and health care policy are linked in ways that, if unattended, could undermine the well-being of a significant portion of the US population, specifically medically underserved rural and urban populations. Using current data from a workforce report of the Association of American Colleges and the published literature, we demonstrate the significant impact that contemporary immigration policy directives may have on the number and distribution of international medical graduates who currently provide-and by the year 2025 will provide-a significant portion of primary health care in the United States, especially in underserved small urban and rural communities.

Two Novel Urban Health Primary Care Residency Tracks That Focus On Community-Level Structural Vulnerabilities.

BACKGROUND: Although residency programs are well situated for developing a physician workforce with knowledge, skills, and attitudes that incorporate the strengths and reflect the priorities of community organizations, few curricula explicitly do so. AIM: To develop urban health primary care tracks for internal medicine and combined internal medicine-pediatrics residents. SETTING: Academic hospital, community health center, and community-based organizations. PARTICIPANTS: Internal medicine and combined internal medicine-pediatrics residents. PROGRAM DESCRIPTION: The program integrates community-based experiences with a focus on stakeholder engagement into its curriculum. A significant portion of the training (28 weeks out of 3 years for internal medicine and 34 weeks out of 4 years for medicine-pediatrics) occurs outside the hospital and continuity clinic to support residents' understanding of structural vulnerabilities. PROGRAM EVALUATION: Sixteen internal medicine and 14 medicine-pediatrics residents have graduated from our programs. Fifty-six percent of internal medicine graduates and 79% of medicine-pediatrics graduates are seeking primary care careers, and eight overall (27%) have been placed in community organizations. Seven (23%) hold leadership positions. DISCUSSION: We implemented two novel residency tracks that successfully placed graduates in community-based primary care settings. Integrating primary care training with experiences in community organizations can create primary care leaders and may foster collective efficacy among medical centers and community organizations.

Routine colonoscopy, diabetic eye care, mammogram and pap smear screening in vascular surgery patients.

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008 / Inequality in access to health services between urban and rural areas in Brazil: a disaggregation of factors from 1998 to 2008 / Desigualdad en el acceso a la salud entre áreas urbanas y rurales de Brasil: una descomposición de factores entre 1998 a 2008

O acesso à saúde é uma importante dimensão das desigualdades entre áreas urbanas e rurais. O acesso é menor nas áreas rurais em função da maior vulnerabilidade social de sua população e das maiores dificuldades de acesso que seus grupos sociais estão submetidos. A partir de dados do suplemento de saúde da Pesquisa Nacional por Amostra de Domicílios, foram analisados os determinantes do acesso e das diferenças entre áreas urbanas e rurais nos anos de 1998 a 2008. A análise dos determinantes do acesso aos serviços de saúde foi realizada pelo modelo de regressão logística binária. As diferenças entre áreas urbanas e rurais foram decompostas em fatores observáveis (fatores de capacitação, necessidade e predisposição) e não observáveis (oferta e dificuldade de acesso). Os resultados destacam que a desigualdade de acesso é elevada e maior nas áreas rurais. Os fatores de necessidade são determinantes fundamentais do acesso à saúde, enquanto que os fatores de capacitação são mais importantes para explicar as diferenças entre as áreas urbanas e rurais. A tênue redução das diferenças no período se deveu fundamentalmente a mudanças na composição da população rural.

Access to healthcare is an important dimension of inequalities between urban and rural areas. Access is lower in rural areas due to the population's greater social vulnerability and greater difficulties in access among its social groups. Based on data from the health supplement of the Brazilian National Household Sample Survey, we analyzed the determinants of access and differences between urban and rural areas from 1998 to 2008. The analysis of determinants of access to health services used binary logistic regression. Differences between urban and rural areas were disaggregated as observable factors (enabling, need, and predisposing) and non-observable factors (supply and difficulty in access). The results highlight that inequality in access is higher in rural areas. Need factors are fundamental determinants of access to health, while enabling factor are more important for explaining the differences between urban and rural areas. The slight reduction in differences during the period was due mainly to changes in the rural population's composition.

El acceso a la salud es una importante dimensión de las desigualdades entre áreas urbanas y rurales. El acceso es menor en las áreas rurales, en función de una mayor vulnerabilidad social de su población y de las mayores dificultades de acceso a la que están sometidos sus grupos sociales. A partir de los datos del suplemento de salud de la Encuesta Nacional por Muestra de Domicilios, se analizaron los determinantes de acceso y diferencias entre áreas urbanas y rurales, desde el año 1998 a 2008. El análisis de los determinantes de acceso a los servicios de salud se realizó mediante un modelo de regresión logística binaria. Las diferencias entre áreas urbanas y rurales se dividieron en factores observables (factores de capacitación, necesidad y predisposición) y no observables (oferta y dificultad de acceso). Los resultados destacan que la desigualdad de acceso es elevada y superior en las áreas rurales. Los factores de necesidad son determinantes fundamentales del acceso a la salud, mientras que los factores de capacitación son más importantes para explicar las diferencias entre áreas urbanas y rurales. La tenue reducción de las diferencias en el período se debió fundamentalmente a cambios en la composición de la población rural.

Challenges in the Medical Management of Symptomatic Intracranial Stenosis in an Urban Setting.

BACKGROUND AND PURPOSE: Since the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis), aggressive medical management (AMM), which includes dual antiplatelet therapy (DAPT) and high-dose statin (HDS) therapy, is recommended for patients with symptomatic intracranial atherosclerotic disease. However, limited data on the real-world application of this regimen exist. We hypothesized that recurrent stroke risk among patients treated with AMM is similar to the medical arm of the SAMMPRIS cohort. METHODS: Using a prospective registry, we identified all patients admitted between August 2012 and March 2015 with (1) confirmed ischemic stroke or transient ischemic attack; (2) independently adjudicated symptomatic intracranial atherosclerotic disease; and (3) follow-up at 30 days. We analyzed 30-day risk of recurrent ischemic stroke stratified by treatment: (1) AMM: DAPT plus HDS therapy, (2) HDS alone, and (3) DAPT alone. We also assessed 30-day risk among patients who met prespecified SAMMPRIS eligibility criteria. RESULTS: Among 99 patients who met study criteria (51.5% male, 54.5% black, mean age 68.2±11.2 years), 49 (48.5%) patients were treated with AMM, 69 (69.7%) with DAPT, and 73 (73.7%) with HDS therapy. At 30 days, 20 (20.2%) patients had recurrent strokes in the territory of stenosis. Compared with the risk in the medical arm of SAMMPRIS (4.4%), the 30-day risk of recurrent stroke was 20.4% in AMM patients, 21.5% in HDS patients, 22.4% in DAPT patients, and 23.2% in SAMMPRIS-eligible patients (all P<0.001). CONCLUSIONS: Recurrent stroke risk within 30 days in patients with symptomatic intracranial atherosclerotic disease was higher than that observed in the medical arm of SAMMPRIS even in the subgroup receiving AMM. Replication of the SAMMPRIS findings requires further prospective study.

Making the Case for Investment in Rural Cancer Control: An Analysis of Rural Cancer Incidence, Mortality, and Funding Trends.

Estimates of those living in rural counties vary from 46.2 to 59 million, or 14% to 19% of the U.S. POPULATION: Rural communities face disadvantages compared with urban areas, including higher poverty, lower educational attainment, and lack of access to health services. We aimed to demonstrate rural-urban disparities in cancer and to examine NCI-funded cancer control grants focused on rural populations. Estimates of 5-year cancer incidence and mortality from 2009 to 2013 were generated for counties at each level of the rural-urban continuum and for metropolitan versus nonmetropolitan counties, for all cancers combined and several individual cancer types. We also examined the number and foci of rural cancer control grants funded by NCI from 2011 to 2016. Cancer incidence was 447 cases per 100,000 in metropolitan counties and 460 per 100,000 in nonmetropolitan counties (P < 0.001). Cancer mortality rates were 166 per 100,000 in metropolitan counties and 182 per 100,000 in nonmetropolitan counties (P < 0.001). Higher incidence and mortality in rural areas were observed for cervical, colorectal, kidney, lung, melanoma, and oropharyngeal cancers. There were 48 R- and 3 P-mechanism rural-focused grants funded from 2011 to 2016 (3% of 1,655). Further investment is needed to disentangle the effects of individual-level SES and area-level factors to understand observed effects of rurality on cancer. Cancer Epidemiol Biomarkers Prev; 26(7); 992-7. ©2017 AACR.

Screening and management practices for renal disease in the HIV-positive patient population of an inner metropolitan sexual health service.

Renal disease is an important and commonly encountered co-morbidity in HIV infection. Despite this, few data are available concerning renal disease in this patient group. A retrospective review was conducted of all HIV-positive patients of an inner metropolitan sexual health service who attended from 1 August 2013 to 31 July 2014 for HIV management. One hundred eighty-eight HIV-positive patients attended the clinic during the study period. The majority were male (96%), Caucasian (70%) and 30-39 years of age (37%). There was a high prevalence of renal risk factors in the population, including potentially nephrotoxic antiretroviral therapy (61%), smoking (38%), hypertension (12%), dyslipidemia (11%) and hepatitis C co-infection (7%). In the previous year, measurements of estimated glomerular filtration rate were performed in all patients, but measurements of lipid profiles, urinary protein and serum phosphate were performed within the last year in only 48%, 33% and 30% of patients, respectively. These are the first comprehensive data regarding renal disease, associated risk factors and screening and management practices in the HIV-positive patient population of a specialized sexual health service in Australia. This patient population demonstrates a particularly high prevalence of risk factors for renal disease. Despite this, screening investigations were not performed as recommended. This represents a potential area to improve patient care.

Impact assessment of a maternal health project in a megacity, Nigeria: toward a future with more demand for maternal health services.

To improve the quantity and quality of maternal health services in Lagos State, Nigeria having a maternal mortality ratio of 555 per 100 000 live births, a four-year project was implemented since February 2010. The major activity of the project was training for both the service supply and demand sides. This study aimed to examine the impact of the project on coverages and quality of the services in target areas, and guide statewide policies. The Cochran-Armitage test for trend was applied to understand trends in the service coverages during 2009-2013. The same test was performed to analyse trends in the proportions of perineal conditions (i.e. intact or tear) and to evaluate variations in midwives' snkill during 2011-2013. The paired t-test was used to analyse changes in midwives' knowledge. The project interventions contributed to a significant increase in the overall service coverages, including improvements in midwifery knowledge and possibly in their skills. However, the service coverage was still limited as of the termination of the project. To instal the interventions and maximise the effect of them state-wide, it is recommended to undertake five tasks: (i) establishment of public primary health centres offering 24-h maternal health services; (ii) redeployment and recruitment of public health personnel; (iii) expansion of midwifery trainings and continuous education by the local trainers; (iv) review of grass-roots level activities; and (v) scrutiny of barriers to maternal health services. Copyright © 2016 John Wiley & Sons, Ltd.

Service readiness, health facility management practices, and delivery care utilization in five states of Nigeria: a cross-sectional analysis.

BACKGROUND: Existing studies of delivery care in Nigeria have identified socioeconomic and cultural factors as the primary determinants of health facility delivery. However, no study has investigated the association between supply-side factors and health facility delivery. Our study analyzed the role of supply-side factors, particularly health facility readiness and management practices for provision of quality maternal health services. METHODS: Using linked data from the 2005 and 2009 health facility and household surveys in the five states in which the Community Participation for Action in the Social Sector (COMPASS) project was implemented, indices of health service readiness and management were developed based on World Health Organization guidelines. Multilevel logistic regression models were run to determine the association between these indices and health facility delivery among 2710 women aged 15-49 years whose last child was born within the five years preceding the surveys and who lived in 51 COMPASS LGAs. RESULTS: The health facility delivery rate increased from 25.4 % in 2005 to 44.1 % in 2009. Basic amenities for antenatal care provision, readiness to deliver basic emergency obstetric and newborn care, and management practices supportive of quality maternal health services were suboptimal in health facilities surveyed and did not change significantly between 2005 and 2009. The LGA mean index of basic amenities for antenatal care provision was more positively associated with the odds of health facility delivery in 2009 than in 2005, and in rural than in urban areas. The LGA mean index of management practices was associated with significantly lower odds of health facility delivery in rural than in urban areas. The LGA mean index of facility readiness to deliver basic emergency obstetric and neonatal care declined slightly from 5.16 in 2005 to 3.98 in 2009 and was unrelated to the odds of health facility delivery. CONCLUSION: Supply-side factors appeared to play a role in health facility delivery after controlling for socio-demographic factors. Improving uptake of delivery care would require greater attention to rural-urban inequities and health facility management practices, and to increasing the number of health facilities with fundamental elements for delivery of basic emergency obstetric and neonatal care.