The patient-centeredness of the consultation among patients with chronic disease: a cross-sectional study of the St. Joseph cluster of health centres in Trinidad and Tobago

Background: Several studies demonstrate patient-centered care enhances patient satisfaction, quality of care and health outcomes while decreasing health care costs and discrepancies in health care. The aims were to measure consultation length, patient's perception of patient centeredness (PPPC) and patient enablement instrument score (PEI) and to determine the patient factors associated with them. Method: A cross-sectional study was conducted over 2 months at four clinics. collecting data from 180 patients (82% response rate) attending. The interviewers timed the consultation as the patients entered and exited the doctor's room. The post-consultation questionnaire comprised demographics, consultation parameters, the PPPC survey (14 questions scored 1-4) and the PEI survey (6 questions scored 0-2). Results: The response rate was 82.5% with a sample of 180 patients. The average, median and mode of quality measures: PPPC average (3.67, 3.86 and 4), PEI score (5.93, 6 and 6) and consultation length (8.5, 7.74 and 10). The PPPC Average was higher in patients without stroke (p=0.022), those with more than 2 consultation interruptions (p=0.015) and those who knew the doctor very well (p=0.015). The PEI score was higher in patients without heart disease (p=0.022). The consultation length was longer in those with tertiary education (p=0.044) and those with two consultation interruptions (p=0.032). PPPC Average and PEI Score correlated well (p=0.408, p<0.001). The consultation length correlated with the PPPC Average (p=0.168, p=0.025). Conclusion: The PPPC Average, PEI Score and consultation length were above average compared internationally. The implementation of a 15-minute appointment system and training programmes for staff in patient-centeredness may improve care for patients. Future study should determine cut-off values for the surveys to assess standard of care.

Obesity: diagnosis and prescription for action in the English-speaking Caribbean

Obesity has been the silent global epidemic of the last 30 years. Almost every country that has statistics has documented a progressive, often dramatic increase. And ironically, while obesity was previously associated with perceptions of wealth and plenty, a large and increasing number of victims today are trapped in poverty and are from developing countries with high levels of poverty, particularly in Latin America and the Caribbean. But unlike AIDS, which appeared "out of the blue" and carries the stigma of both infections and fatal features, obesity, as an epidemic, has been insidious, is not infectious in the accepted sense, and leads to death indirectly and surreptitiously. It has therefore been ignored as the major public health problem that it most surely is . This paper will briefly outline the dimensions of the problem in the English-speaking Caribbean; its enormous impact on health, quality of life, morbidity, mortality, and health care costs; its major causes; and a prescription for concerted, urgent regional action (AU)

The dilemma of diabetes: health care crisis in the Caribbean

The epidemiologic transition in the Caribbean over the last 40 years has produced an epidemic of life-style-related chronic noncommunicable diseases. Among these are obesity, diabetes, and hypertension, along with such complications as stroke, heart disease, and amputations. The World Health Organization projects that the number of adults with diabetes in the Americas will double by 2025, and that most of the increase will occur in Latin America and the Caribbean. Both obesity and diabetes have been been increasing in Barbados (2-4), in Trinidad (5,6), and in Jamaica (7-9). Obesity (body mass index (BMI) > 30 kg/m) already occurs in 30 percent of Barbadian women 25-75 years old, and overweight (BMI >25 kg/m) in 57.8 percent of them. Diabetes occurs in 17 percent of persons over age 25, according to one study, and in 13.4 percent, according to another study. The combination of a rapid increase in calorie intake and a decrease in physical activity, against a background of cultural traditions that favor female obesity, imposes an unmanageable burden on the limited health care resources of these small countries of the Caribbean (AU)

Investment in health: social and economic returns

This publication brings together the final reports from three research projects that explored how investments in health affected economic growth, household productivity, and poverty alleviation in Latin America and the Caribbean. The projects were carried out in 1998 and 1999, and came about through the coordinated efforts of the Pan American Health Organization (PAHO), the Inter-American Development Bank (IDB), the United Nations Development Program (UNDP), the United NAtions Economic Commission for Latin America and the Caribbean (UNECLAC), and the World Bank

Gasto y financiamiento en salud: situacion y tendencias / Health spending and financing: the current situation and trends

Being knowledgeable about national health expenditures and sources of financing is essential for decision-making. This awareness also makes it possible to evaluate the equity of allocation and the efficiency of utilization of these resources. Changes in the financing have been a substantial component of health sector reform in the Americas. The goal has shifted from merely one of financial sustainability to simultaneously seeking equitable access to quality services. In this article the PAn American Health Organization (PAHO) presents a proposal for analyzing and designing a policy on health financing. The aim of the policy is to identify the mix of financing mechanisms most likely to simultaneously produce financial sustainability, equity, access, and efficiency. The PAHO proposal combines traditional mechanisms for generating resources (public funds from taxes, as well as private health insurance, national health insurance, and user fees) with complementary subsidy mechanisms for vulnerable groups. Health financing strategies ought to explicitly consider the financing both of care for individuals and of health interventions for the general public good, for which public financing is the most equitable and efficient approach (AU)

Trauma aetiology and cost in the Accident and Emergency Unit of the University of the West Indies

Trauma accounted for 37 percent of 22,311 patients seen in the Accident and Emergency Unit (A&E) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine percent of injuries were intentional and 18 percent were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75 percent of the injuries compared with 5 percent for gunshot wounds. Passengers were injured in about 40 percent of motor vehicle accidents and pedestrians in 19 percent. The admission rate was 16 percent and the orthopaedic clinic received 75 percent of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24 percent) than those of unintentional violence (13 percent). The average cost of caring for each patient in the A&E Unit was US$70 resulting in an annual cost of US$578,000.(AU)

Informing maternal and child health (MCH) policy through research

Maternal and Child Health (MCH) policy over the past two decades has been strongly influenced by research. The paper presents examples of some of the research undertaken and its significant influence in shaping health service delivery. Research in child health has focussed on oral rehydration therapy, immunization and perinatal morbidity and mortality. On the maternal side, morbidity and mortality have been examined with particular focus on problems which contribute to maternal and perinatal morbidity and mortality. Policies arising out of the outcome of these studies have influenced organization of service delivery, information system development, manpower development and deployment, maternal education, surveillance/auditing, quality of care, design of physical facilites and selection of equipment. The results of these studies have also led to the identification of areas requiring further study and testing of intervention to correct the deficiencies identified. These studies demonstrate that research can and does influence health policy, and has impacted positively on the quality and cost of care provided through our health services.(AU)

Stroke in Trinidad and Tobago: Burden of illness and risk factors

This study describes the burden of stroke on hospital services in a Caribbean community. The settings are the two main acute general hospitals in Trinidad observed over a 12-month period. All subjects are admitted with a clinical diagnosis of acute stroke. The measures were hospital admission rates, length of hospital stay, case-fatality rates, disability at discharge, and risk factors for stroke. There were 1,105 hospital admissions with a diagnosis of stroke. The median length of stay was 4 days, with an interquartile range of 2 to 9, and stroke accounted for approximately 9,478 bed days per annum. The hospital admission fatality rate was 29 percent. Among surviving patients, 437 (56 percent) were severely disabled at discharge. Age-standardized admission rates for first strokes in persons aged 35-64 years were 114 (95 percent CI: 83 to 145) per 100,000 in Afro-Trinidadian men and 144 (109 to 179) in Indo-Trinidadian men. The equivalent rates for women were 115 (84 to 146) and 152 (118 to 186). Among patients with first strokes, 348/531 (66 percent) reported physician-diagnosed hypertension, but only 226 (65 percent) of these reported being on antihypertensives at admission. Stroke in Trinidad and Tobago is associated with a high case-fatality rate and severe disability in survivors. Modifable risk factors were reported in a majority of stroke cases, and there is a need to develop effective preventive strategies.(AU)

Hospitals in Latin America and the Caribbean

Health service provided by public or private institutions at the primary and hospital referral levels should be coordinated so that the available resources are distributed equitably to meet the needs and aspirations of the population. The challenge is to improve the quality of hospital care and the existing pattern of public and private services in Latin America and the Caribbean.(AU)

Counting the cost of hospital admissions with stroke in the Port-of-Spain and San Fernando, Trinidad

Cerebrovascular disease is one of the leading causes of death in Caribbean countries, but few studies have examined the use of hospital services by people suffering from stroke. We studied all patients admitted to Port-of-Spain and San Fernando hospitals in Trinidad over a twelve-month period. There were 643 admissions at Port-of-Spain Hospital and 462 at San Fernando. There were 823 (74 percent) admissions with first time strokes and 282 (26 percent) admissions with recurrent stroke; 321 (29 percent) were aged 65-74 years and 324 (29 percent) were 75 years of age. Five hundred and nine (46 percent) were Afro-Trinidadian and 418 (38 percent) Indo-Trinidadian but ethnic distribution differed at the two hospitals. There were clinical diagnoses of hypertension in 693 (63 percent) and diabetes mellitus in 355 (32 percent). There were 322 deaths giving a hospital admission fatality rate of 29 percent (95 percent CI, 26-32 percent). Mortality was associated with level of consciousness and degree of impairment of speech, swallowing and continence at the time of first assessment. Hospital mortality was not associated with age, gender, ethnic group or hospital of treatment. Among surviving patients 444 (57 percent) were severely disabled at the time of discharge. The median length of stay was 4 days (interquartile range 2-8 days) at Port-of-Spain and 5(3-9) days at San Fernando. At the two hospitals admissions with stroke accounted for 9088 bed-days annually with a conservatively estimated hospital cost in excess of TT $3.6 million (US$ 0.63). We conclude that stroke imposes a significant burden on hospital services, the hospital mortality rate is high and survivors have significant disability. The high prevalence of hypertension in stroke sufferers points to a strategy for control of stroke (AU)

Selective privatization a model for funding health care services in developing countries - abstract

In the Bahamas, a group of staff physicians, the Physician Alliance, proposed the privatization of selective health services in the public hospital, to provide universal access and availabiltiy of "modern" health care services at an affordable cost. The initial project outlined for the physician group to provide capital funds to establish and manage an Ultrasonic diganostic facility. Charges for procedures would reflect the government's subsidy of its public institution; reduced costs for procedures, differential fees for public patients and procedures, to be performed at no charge to the indigent patient. The hospital would provide the physical site, utilities and excise duties in the purchased equipment. Net profits were to be shared equally between the Hospital and the Physician group. The Physician Alliance provided an initial capital fund of US$86,000. The first year financial audit revealed fixed assets of $300,000. The one-year revenue of $270,000 yielded a 20 percent return to the physician share holders. The cost providing diagnostic services to indigent patients accounted for 7.4 percent of total revenues. The hospital, in addition to its profit share, collects 7 percent in management fees. Funds were allocated also for physicians to attend training courses in relevant diagnostic procedures and non-physicians to pursue certification courses to become ultrasound technicians. The privatization project is being expanded to include endoscopic equipment and an operating room surgical suite; capitalization projected - $800,000. We believe that selective privatization has advanced health care delivery in the public institution; simultaneously it has fostered physician involvement in the hospital's strategic planning and implementation of patient-related heath care services (AU)