The employment of dental hygienists in European countries: Report of a European Dental Hygienists Federation/European Association of Dental Public Health Survey in 2021.

AIM: This survey aimed to investigate a range of topics relating to the employment of dental hygienists in European countries, whose National Dental Hygienists Associations (NDHAs) were members of the EDHF. METHODS: During 2020/2021, an online questionnaire and participant information leaflet were distributed by email in each of the 24 countries, whose NDHA is a member of the EFDH or to an EADPH member who was likely to respond. RESULTS: The broad term employment of dental hygienists was taken to include current numbers, place of work (public or private clinics and other locations), whether they were currently working as dental hygienists, their pay, any planned changes in their employment and their participation in continuing education. Twenty-four countries (92%) responded. Hungary and Poland reported that fewer than 35% of their qualified dental hygienists were working as dental hygienists. In 10 countries, often for family reasons, over 40% worked part-time. In 14 countries, over 70% worked in private clinics. Average annual pay ranged from €8400 in public clinics in Poland to €106,000 in dental hygienist-owned clinics in Denmark Regular participation in continuing education was mandatory in only nine countries. CONCLUSIONS: Dental hygienists play a different role within the oral healthcare system in each European country. There is a wide variation in their education, places of employment, annual pay and continuing education requirements.

The development of digital dentistry in the UK: An overview.

The COVID-19 pandemic has highlighted the benefits which digital technology offers to all aspects of dental practice and education. This paper provides an overview of how digital technology has enhanced clinical and administrative procedures within dental practice, including computer-aided design/computer-aided manufacture (CAD/CAM), digital radiography, 3D printing, patient records, electronic patient referrals and electronic communications from dental practices. It then considers the development of teledentistry (mHealth) and its benefits in enabling distant consultations with patients, who for one reason or another are unable to visit dental practices easily. It then goes on to consider how and why digital dental distance learning materials were provided to general dental practitioners in England by the Department of Health (DoH) (England) and how they evolved. Finally, this paper considers the use of digital technology in dental education by dental schools.

Fetal maturation revealed by amniotic fluid cell-free transcriptome in rhesus macaques.

Accurate estimate of fetal maturity could provide individualized guidance for delivery of complicated pregnancies. However, current methods are invasive, have low accuracy, and are limited to fetal lung maturation. To identify diagnostic gestational biomarkers, we performed transcriptomic profiling of lung and brain, as well as cell-free RNA from amniotic fluid of preterm and term rhesus macaque fetuses. These data identify potentially new and prior-associated gestational age differences in distinct lung and neuronal cell populations when compared with existing single-cell and bulk RNA-Seq data. Comparative analyses found hundreds of genes coincidently induced in lung and amniotic fluid, along with dozens in brain and amniotic fluid. These data enable creation of computational models that accurately predict lung compliance from amniotic fluid and lung transcriptome of preterm fetuses treated with antenatal corticosteroids. Importantly, antenatal steroids induced off-target gene expression changes in the brain, impinging upon synaptic transmission and neuronal and glial maturation, as this could have long-term consequences on brain development. Cell-free RNA in amniotic fluid may provide a substrate of global fetal maturation markers for personalized management of at-risk pregnancies.

Periodontal Care and Treatment Provision by General Dentists in France.

AIM: In many countries, periodontal surgery is mainly provided by periodontists. This specialty is not recognised in France, where periodontal care and treatment are principally the responsibility of general dentists (GDs). The objective of this study was to investigate the periodontal care provided and factors associated with the treatment of periodontal diseases, including periodontal surgery, by GDs in France. METHODS: A national cross-sectional survey of GDs practicing in the French metropolitan area was conducted in 2019. A self-administered questionnaire was sent by mail to the GDs selected by stratified simple random sampling. It included questions on respondents' sociodemographic characteristics and their periodontal practice. A multivariate logistic regression model was employed to identify the factors associated with the practice of periodontal surgery by GDs. RESULTS: Three hundred eighty-five GDs responded (response rate, 23.4%). Their mean age was 45.2 years; 51.2% were male and 83.6% were in private practice. They reported performing selective periodontal examinations such as pocket probing on average for 34.2% of their patients, but only 5.5% of them performed them systematically. Several variables were significantly associated with the provision of periodontal surgical procedures such as the gender of the GDs, full mouth periodontal probing, implantology practice, insufficient fees, or uncertainty about treatment procedure. This survey confirmed the referral of patients for periodontal surgery by a minority of practitioners. It also highlighted insufficient screening and diagnostic procedures for periodontal diseases by GDs. CONCLUSIONS: There is a need to improve French GDs' periodontal skills and knowledge and to address other barriers that currently limit their ability to deliver comprehensive periodontal care.

Comparing oral health systems for children in six European countries to identify lessons learned for universal oral health coverage: A study protocol.

Background: Oral diseases have the highest global prevalence rate among all diseases, with dental caries being one of the most common conditions in childhood. A low political priority coupled with a failure to incorporate oral health within broader health systems has contributed to its neglect in previous decades. In response, calls are emerging for the inclusion of oral health within the universal healthcare domain (UHC). This protocol outlines the methodology for a cross-country comparative analysis of publicly funded oral health systems for children across six European countries, reporting on oral health status in line with the indicators for UHC. Methods: This study will follow Yin's multiple case study approach and employ two strands of data collection, analysis, and triangulation: a systematic documentary analysis and semi-structured interviews with elite participants local to each country. The countries chosen for comparison and providing a representative sample of European dental systems are Denmark, Hungary, the Republic of Ireland, Germany, Scotland, and Spain. A systematic search of five electronic databases and four additional electronic resources will be undertaken, in addition to grey literature and other publicly available sources, with the outcomes verified and further informed by local experts. The WHO Universal Health Coverage Cube will be used to guide data collection and analysis. Conclusions: This research will provide policy makers with an in-depth analysis and comparison of publicly funded oral health systems for children in Europe, including consideration of effective preventive strategies, oral health system reform, and indicators of universal oral health coverage. It is anticipated that the outcomes may help in positioning oral health on governmental health agendas and support its integration into wider health systems' reform in an accessible and affordable manner.

European Federation of Periodontology Survey of Postgraduate and Specialist Training in Europe in 2020.

AIMS: The survey's aim was to establish which universities and other educational organisations deliver postgraduate and specialist training in Periodontology in the 31 countries who are members of the European Federation of Periodontology (EFP) and to obtain details of how these programmes are organised, funded, regulated and evaluated. METHODS: A questionnaire and covering letter were emailed to all national periodontal societies. The questions were on the name of country, official recognition, training programmes, entry to specialist training, specialist training assessment and recognition after completion of training. RESULTS: Twenty-nine (93%) of national periodontal societies responded. Key findings included the following: Periodontology was reported as being recognised at a national level in 17 countries, there was a three-year full-time programme in 12 countries, no fees were charged for specialist training in 10 countries, in 14 countries trainees received annual salaries, end of training (summative) assessments varied from country to country, 12 countries reported that they had a requirement for specialists in Periodontology to complete continuing education to maintain registration as specialists. CONCLUSIONS: This survey has established which universities and other educational organisations deliver postgraduate and specialist training in Periodontology and how these programmes are organised, funded, regulated and evaluated. To provide uniformly high-quality periodontal care for patients in all European countries, further harmonisation of postgraduate and specialty training in Periodontology would be advantageous.

The prevalence of potentially undiagnosed type II diabetes in patients with chronic periodontitis attending a general dental practice in London - a feasibility study.

Introduction In the UK alone, it is estimated that one in four people with type II diabetes are currently undiagnosed.Aim To investigate the prevalence of potentially undiagnosed type II diabetes in patients with chronic periodontitis attending a general dental practice in North London.Methods Patients aged 35 years and over, who had not been diagnosed with diabetes, attending for routine examination and diagnosed with chronic periodontitis, were offered screening for diabetes risk using the self-reporting Finnish Diabetes Risk Score (FINDRISC) questionnaire. If the score showed an increased risk of developing type II diabetes, a referral letter was sent to their general medical practitioner (GMP) for formal testing. The uptake and results of the test were recorded.Results Over the 12-month period, a total of 51 patients were eligible to take part, with 40 agreeing to participate (78% participation rate). Nineteen participants (48%) were found to be at a significantly increased risk of developing type II diabetes based on the recommended FINDRISC cut-off point and were referred to their GMP for formal testing. Eleven participants (58%) scored above the FINDRISC cut-off point and were categorised as high-risk. A further six participants (32%) fell into the moderate-risk category and two participants (10%) fell into the slightly elevated-risk category. Of the 19 participants who were referred for formal testing, four were not found to have type II diabetes, nine were found to have intermediate hyperglycaemia (or prediabetes) and two participants were diagnosed with type II diabetes.Conclusions This study confirmed a method of diabetes risk screening that has a good rate of uptake by patients and is practical for use in general dental practice. A moderate proportion of patients were identified as having an increased risk of developing diabetes and just under half were referred for formal testing. The study has shown an effective method for identifying undiagnosed type II diabetes and prediabetes in patients diagnosed with periodontitis who attend general dental practice.

An internet-mediated investigation into the reported clinical use of rubber dam isolation by GDPs in the UK - part 2: clinical applications.

Aims To investigate the reported clinical applications of rubber dam isolation by UK general dental practitioners (GDPs) using an internet-mediated approach.Methods The data were collected in 2019, using an online (SurveyMonkey) questionnaire that was distributed to GDPs in a private group on Facebook. The percentages are based on the number of respondents who answered each question.Results The response rate was 61% with 403 valid completed questionnaires. The majority (395; 98%) of respondents reported using rubber dam in clinical practice. Undergraduate training in rubber dam use was received by 382 (98%) respondents, with greater training reported by younger, more recently qualified graduates. The main clinical applications of rubber dam included its use for composite restorations, endodontic treatments and internal bleaching procedures, while for other clinical procedures, the majority of respondents did not use rubber dam. For posterior and anterior composites, 332 (82%) and 298 (74%) respondents, respectively, reported using rubber dam isolation at least rarely. At least 98% (395) of the respondents used rubber dam for endodontic procedures, irrespective of tooth type and position. Over 70% (281) of respondents reported using rubber dam at least rarely for internal bleaching. Rubber dam was used by 99% (392) and 67% (262) of respondents on adults and paediatric patients, respectively.Conclusions The main clinical applications agree with previous reports, but highlight an increase in rubber dam use. This study investigated a wider range of clinical applications compared to previous studies, adding to the literature surrounding rubber dam use.

An internet-mediated investigation into the reported clinical use of rubber dam isolation by GDPs in the UK - part 1: factors influencing rubber dam use.

Aims To investigate the reported use of rubber dam isolation by UK general dental practitioners (GDPs), utilising an internet-mediated (SurveyMonkey) questionnaire reporting the demographic profile of respondents and the attitudes and factors influencing rubber dam use.Methods A piloted questionnaire was distributed to a random sample of GDPs in a private Facebook group, investigating respondent demographics, clinical applications, and attitudes towards and factors influencing rubber dam use. The data were analysed using descriptive statistics along with chi-squared and pairwise Mann-Whitney U tests.Results The response rate was 61%, with 403 valid completed questionnaires. Of these, 218 (54%) were female and 185 (46%) were male, with an age range of 23-72 years. Most of them (248; 62%) worked in mixed practices. The majority agreed that rubber dam aids placement of posterior restorations (311; 78%), provides clearer access (308; 76%), enables a higher clinical standard (355; 89%) and increases restoration longevity (257; 65%). Most agreed that proper isolation for root canal/operative procedures cannot be achieved without rubber dam use (329; 82%). Respondents disagreed with the following statements: root canal therapy completed without rubber dam isolation is as successful as those completed using rubber dam (338; 85%), rubber dam is difficult to apply (292; 73%) and rubber dam is disliked by patients (257; 64%). Respondents agreed that rubber dam use is influenced by clinical setting (259; 64%), procedure (390; 97%), choice of material being placed (382; 95%) and ease of application (337; 84%). Furthermore, 218 (54%) of the respondents expressed an interest in further training in rubber dam use.Conclusions This study provides greater insight into the attitudes and factors influencing rubber dam use, while demonstrating an interest in further training.

An investigation into possible factors that may impact on the potential for inappropriate prescriptions of antibiotics: a survey of general dental practitioners' approach to treating adults with acute dental pain.

Objective To investigate factors that might influence inappropriate prescriptions of antibiotics (ABs) by UK-based general dental practitioners (GDPs) in their management of acute dental pain in adults in primary dental care.Methods A questionnaire was circulated via social media to UK-based GDPs. The questionnaire examined GDPs' likelihood of issuing an inappropriate AB in two hypothetical clinical scenarios.Results A total of 205 questionnaires were completed, of which 198 were included for analysis. The resulting data were analysed to try and identify factors that correlated with an increased likelihood of an inappropriate AB prescription being issued for each clinical scenario. The results suggested the following factors as being associated with a statistically greater chance of the survey respondent issuing an inappropriate AB prescription: no postgraduate qualification; received their primary dental qualification from a non-UK university; scheduled appointments of less than 20 minutes; and low confidence in their ability to provide adequate local anaesthesia for the patients in the clinical scenario.Conclusions Four factors were shown to be associated with dentists' stated intention to prescribe ABs for acute dental pain, not in accordance with guidance. These results should guide further research to understand the significance of appropriate AB prescribing on the quality of urgent dental care. While the total number of respondents was too low to enable the results to be generalised, it is hoped that the results may help guide future research. Further studies could focus on these factors to understand more about their impact on the urgent care of adult patients in pain. The impact of the restrictions caused by the response to COVID-19 needs to be considered.

Mouth care training and practice: a survey of nursing staff working in National Health Service hospitals in England.

Background: This study investigated the training and mouth care practice of nursing staff in hospital Trusts across England. Oral health has been found to deteriorate during hospital admission, mouth care standards have been found to be poor. Aims: The objectives of the study were to assess if and what the barriers are to supporting inpatients' mouth care, and to assess how confident nursing staff are in carrying out mouth care assessments and mouth care and see if this is related to previous training. Methods: A cross-sectional descriptive survey was conducted in 33 Trusts in England with 1576 members of the nursing team including nurses and nursing assistants. Nursing staff were asked to complete a questionnaire on previous oral health training and their current practice. Results: Nursing staff reported that they had limited training in mouth care. The main barriers to mouth care were time and patient compliance. Confidence in recognising oral cancer was low. Conclusions: Nursing staff would benefit from mouth care training targeted at assessing the mouth and providing mouth care for all inpatients.

Service evaluation of the paediatric dental general anaesthesia service in NHS Lothian.

Objective To gain insight into the reasons for children undergoing dental treatment under general anaesthesia in NHS Lothian.Methods This service evaluation was based on a representative sample size of 294 patients, randomly selected from the 1,236 children seen for dental general anaesthesia (DGA) during 2017 in NHS Lothian. Data on patient and treatment descriptors were collected retrospectively from clinical records and analysed to identify significant correlations.Results The data indicated paediatric DGAs were mostly provided due to dental caries (88%, 260/294) and for children from the most deprived areas of Lothian. Most children were referred because they were of a very young age or had needs which precluded treatment under local anaesthesia (LA). Almost every child had teeth extracted under DGA (99%, 290/294) and a third of children received restorations (33%, 96/294).Discussion and conclusion This study highlighted the disproportionate increased risk of dental caries and DGA in children from more deprived backgrounds, despite a nationwide reduction of children with caries experience. There is a need for more holistic, whole-system approaches to reduce child dental caries, with opportunities for collaborative work with local stakeholders to follow-up children who have had DGA. More research is needed locally and nationally to inform the translation of evidence into effective interventions.

Motivation to Follow a Career in Dentistry of Students in Three South-East European Countries.

OBJECTIVE: To investigate and compare the factors that motivated students to study dentistry in countries with similar background (Albania, Croatia and the Republic of Northern Macedonia) and to assess whether or not their motivation changed during time. MATERIAL AND METHODS: In 2014/2015, cross-sectional studies were conducted in state funded dental schools in Tirana (Albania), Zagreb (Croatia) and Skopje (Macedonia) to assess student views on their career motivation. All dental students from the first, third and final years of study were invited to participate. The participation was voluntary and anonymous. A five-item questionnaire was translated into languages of the participating countries. Ethics approval was granted by the Ethics Committee of the University of Saints Cyril and Methodius, Skopje. The Chi square test was used to test if there were statistically significant differences in answers between students in 3 countries, furthermore between years of the study. RESULTS: The total number of respondents was 739 (319 in Tirana, 211 in Zagreb and 208 in Skopje) The differences in the answers between the first-year students from all three countries were statistically significant (χ2=82.65; p<.01). The most striking answer was to the question on parents' pressure to study dentistry, which was far more frequent in Tirana (up to 27.7%). A "positive image" was the most frequent response from students from Zagreb (up to 79.7%), but it declined from the first to the final year in Skopje. There were also significant differences between the schools within the 3rdand final years of study. CONCLUSIONS: A positive image of dental profession was the main reason for students studying dentistry at all three schools; as many as 97% of the students of the final year in Croatia, a member of the European Union (EU). In the two non-EU countries (Albania, Macedonia) it seemed that dental profession does not have such good status and student expectations are not being fulfilled, especially in Skopje (up to 33.9% willing to change their vocation and up to 64.5% lost their motivation to study) One of the strategies to improve the situation could be to include more clinical practice and to better organize the study..

Oral healthcare workforce planning in post-Brexit Britain.

The terms of the United Kingdom's (UK's) departure from the European Union (EU) are currently being negotiated. It is therefore uncertain exactly what effect they will have on planning the UK's oral healthcare workforce. Nevertheless, as 16% of dentists currently registered with the Genral Dental Council (GDC) have migrated to the UK from EU countries, this factor must be taken into consideration by workforce planners. However, it is far from being the only factor. This opinion piece therefore describes the current numbers of non-UK EU dentists and DCPs registered with the GDC and poses the question 'will they remain in the UK in the future'? It then comments on the current legislation on recognition of non-UK dental qualifications. It goes on to consider the Migration Advisory Committee's recommendation for dental practitioners, the oral healthcare needs of the population of the UK, who could address them and the implications for the Advancing Dental Care project.

An investigation into how general dental practitioners in Leeds manage complex tooth wear cases.

Introduction Restoring complex tooth wear (TW) cases is technically challenging and not well-remunerated under the NHS General Dental Service (GDS) contract. Therefore, numbers of referrals to secondary care are increasing, but these are often rejected as dental hospitals have a high workload. This may make it difficult for patients with TW to access appropriate care unless paying privately, which may be costly for them.Aim The aim of this investigation was to understand how general dental practitioners (GDPs) in Leeds manage complex TW cases.Methods A postal questionnaire was designed and piloted before postal distribution to all GDPs with a Leeds postcode (n = 289). Non-responders were sent reminders to complete the questionnaire. The questionnaire included questions on the place of qualification and experience of the dentists, their management of an example complex TW case and the potential barriers to management of similar cases. The resulting data were statistically tested using Kruskal-Wallis and Mann-Whitney tests.Results A total of 148 (51%) responded to the questionnaire. There was low confidence in restoring complex TW cases with a mean score of 4.65 out of 10 (0 being not confident at all and 10 being very confident). Only 30 respondents (21%) reported that they would treat complex TW cases under the current NHS GDS contract, and 90 (62%) reported that they had experienced difficulty referring these cases to hospital. Kruskal-Wallis testing showed increased confidence in restoring by those with a diploma or MSc (p = 0.004 and p = 0.014 respectively). Mann-Whitney testing showed those undertaking a higher percentage of NHS work were less likely to restore these cases (U = 2,100; p = 0.02).Conclusion These results suggest that Leeds patients with complex TW may have difficulty in accessing appropriate care under the current NHS GDS contract. The results highlight the benefits of postgraduate education on confidence in restoring complex TW cases.

Knowledge, dentist confidence and management of periodontal patients among general dentists from Belarus, Lithuania, Macedonia, Moldova and Romania.

BACKGROUND: Evidence concerning periodontal practice in Eastern European countries is scarce. The aim of the present study was to investigate periodontal risk knowledge, patient management and self-perceived confidence among General Dentists (GDs) from five Eastern European regarding their provision of periodontal care. METHODS: GDs from Belarus, Lithuania, Macedonia, Moldova and Romania participated in a questionnaire survey. Power calculations were used to identify the sample size for each country. The structured questionnaire included several domains of inquiry. The socio-demographic domain inquired about dentist's age, gender and years of clinical experience. The dental practice domain inquired about practice location, practising or not practising in a group practice and having or not having a periodontist or a dental hygienist in the practice. The distributions of answers across-countries were compared employing one way ANOVA (comparison of means) or Chi square test (comparison of proportions). For each country, the predictors of the study outcomes: a summative knowledge score for periodontal risks and dentist's confidence level were identified employing either linear or logistic multiple regression models. RESULTS: The sample comprised 390 Belarussian, 488 Lithuanian, 349 Macedonian, 316 Moldovan, and 401 Romanian GDs. The majority of GDs (~ 80%) practiced in urban areas. Age and gender distributions differed significantly among countries. Significant across-country differences were found regarding working/not working in a group practice, having/not having access to a periodontist/dental hygienist and in proportions of patients receiving periodontal treatments or being referred to specialists. None of Macedonian patients nor the majority of Moldovan patients (78%) were referred to periodontists. There were also significant across-country differences in diagnosis, patient management and periodontal knowledge. Only in the Lithuanian cohort were dentists' confidence levels associated significantly with their knowledge. In all countries, taking a medical history was a consistent and significant predictor of having higher periodontal knowledge score. Except in Belarus, periodontal risk assessment was a significantly consistent predictor of certainty levels associated with the provision of periodontal treatments. CONCLUSIONS: There were substantial differences among GDs in the five countries regarding diagnosis, dentist's confidence and management of periodontal patients.

The System of The Provision of Oral Healthcare in the Republic of Cyprus and the Effect of the Economic Crisis.

PURPOSE: To investigate recent developments in the provision of oral healthcare in Cyprus and the population's oral health, with special reference to the impact of the recent economic crisis. RESEARCH DESIGN: cross-sectional study. MATERIALS AND METHODS: Data from oral health surveys in Cyprus over the last 30 years were reviewed and analysed together with policy documents. Information regarding oral health behaviour, dental visits and the consequences of the economic crisis on the latter was also obtained with the help of self-completed questionnaires by patients and dentists. RESULTS: Although the overall level of oral health in Cyprus can be considered satisfactory, there were statistically significant variations between districts and different socioeconomic and ethnic groups. Beyond these variations, it seemed that the three-year economic crisis (2013-2016) had negatively affected the behaviour of the population in seeking dental care, reducing the frequency of visits to the dentist, and avoiding costly dental work, especially among those from the lower socioeconomic strata. This change in citizens' behaviour led to a statistically significant decrease in dentists' income in the private sector. CONCLUSIONS: The economic crisis brought about new difficulties and challenges for both the public and the private sectors of oral healthcare, and into the implementation of a new National Health System.

The appropriateness of oral surgery referrals and treatment in contracted intermediate minor oral surgery practices in East Kent.

Objectives To assess the appropriateness of oral surgery referrals, after triage, to intermediate minor oral surgery (IMOS) practices in East Kent and whether or not referrals vary according to the referring general dental practitioner's (GDP's) place of qualification and experience.Design A retrospective study of the records of 441 triaged referrals sent to three IMOS practices in East Kent, over a ten-week period. An assessment tool was developed in line with local and national referral guidelines. Information on all referrals was obtained from the IMOS provider and referral records. Descriptive analysis of the data was performed.Results The most common reason for referral was for extraction of teeth requiring bone removal (n = 155; 35%). However, the majority of teeth removed were recorded as a non-surgical extraction (n = 363; 82%). Medical histories were included appropriately in the referral communications, with only 0.2% of all referrals being inappropriate. The proportion of appropriate and inappropriate referrals was very similar and it was found that referral rate was lower from dentists who had been qualified for more than ten years. GDPs working in the same location as the IMOS provider made a greater total number of referrals as well as more inappropriate referrals.Conclusions In the group of GDPs and IMOS providers studied, a wide variation was observed between the GDP's reason for referral and the treatment provided. It may be concluded that the vast majority of extractions were safely completed in an IMOS dental practice in a primary care setting.

The healthcare systems and provision of oral healthcare in European Union member states. Part 10: comparison of systems and with the United Kingdom.

Since 2015, a series of papers which describe the systems for the provision of health and oral healthcare in nine European Union (EU) countries (France, Germany, Greece, Ireland, Italy, Poland, Romania, Spain and Sweden) have been published in this journal. This tenth and final paper in the series compares aspects of the systems for each country, with each other and with that in the United Kingdom (UK). The topics which have been covered are the organisation and funding of oral healthcare, national populations and oral healthcare workforce, education of dentists, uptake of oral healthcare, expenditure on oral healthcare and oral epidemiology. The comparison shows that there are wide differences between the care provision systems between the individual countries. In all of them, oral healthcare continues to operate outside the mainstream healthcare systems. In particular, the proportion of costs paid for them from public funds, raised through taxation or through compulsory social insurances, and those paid for by individual patients varies greatly. No comparable data exist on quality of care.