Relationships between the Structural Characteristics of General Medical Practices and the Socioeconomic Status of Patients with Diabetes-Related Performance Indicators in Primary Care.

The implementation of monitoring for general medical practice (GMP) can contribute to improving the quality of diabetes mellitus (DM) care. Our study aimed to describe the associations of DM care performance indicators with the structural characteristics of GMPs and the socioeconomic status (SES) of patients. Using data from 2018 covering the whole country, GMP-specific indicators standardized by patient age, sex, and eligibility for exemption certificates were computed for adults. Linear regression models were applied to evaluate the relationships between GMP-specific parameters (list size, residence type, geographical location, general practitioner (GP) vacancy and their age) and patient SES (education, employment, proportion of Roma adults, housing density) and DM care indicators. Patients received 58.64% of the required medical interventions. A lower level of education (hemoglobin A1c test: ß = -0.108; ophthalmic examination: ß = -0.100; serum creatinine test: ß = -0.103; and serum lipid status test: ß = -0.108) and large GMP size (hemoglobin A1c test: ß = -0.068; ophthalmological examination ß = -0.031; serum creatinine measurement ß = -0.053; influenza immunization ß = -0.040; and serum lipid status test ß = -0.068) were associated with poor indicators. A GP age older than 65 years was associated with lower indicators (hemoglobin A1c test: ß = -0.082; serum creatinine measurement: ß = -0.086; serum lipid status test: ß = -0.082; and influenza immunization: ß = -0.032). Overall, the GMP-level DM care indicators were significantly influenced by GMP characteristics and patient SES. Therefore, proper diabetes care monitoring for the personal achievements of GPs should involve the application of adjusted performance indicators.

Cross-sectional comparison of health care delivery and reimbursement between segregated and nonsegregated communities in Hungary.

Introduction: Spatially segregated, socio-economically deprived communities in Europe are at risk of being neglected in terms of health care. In Hungary, poor monitoring systems and poor knowledge on the health status of people in these segregated areas prevent the development of well-informed effective interventions for these vulnerable communities. Aims: We used data available from National Health Insurance Fund Management to better describe health care performance in segregated communities and to develop more robust monitoring systems. Methods: A cross-sectional study using 2020 health care data was conducted on each general medical practice (GMP) in Hungary providing care to both segregated and nonsegregated (complementary) adult patients. Segregated areas were mapped and ascertained by a governmental decree that defines them as within settlement clusters of adults with low level of education and income. Age, sex, and eligibility for exemption certificate standardized indicators for health care delivery, reimbursement, and premature mortality were computed for segregated and nonsegregated groups of adults and aggregated at the country level. The ratio of segregation and nonsegregation specific indicators (relative risk, RR) was computed with the corresponding 95% confidence intervals (95% CI). Results: Broad variations between GMPs were detected for each indicator. Segregated groups had a significantly higher rate of health care service use than complementary groups (RR = 1.22, 95% CI: 1.219;1.223) while suffering from significantly reduced health care reimbursement (RR = 0.940, 95% CI: 0.929;0.951). The risk of premature mortality was significantly higher among segregated patients (RR = 1.184, 95% CI: 1.087;1.289). Altogether, living in a segregated area led to an increase in visits to health care services by 18.1% with 6.6% less health spending. Conclusion: Adults living in segregated areas use health care services more frequently than those living in nonsegregated areas; however, the amount of health care reimbursement they receive is significantly lower, suggesting lower quality of care. The health status of segregated adults is remarkably lower, as evidenced by their higher premature mortality rate. These findings demonstrate the need for intervention in this vulnerable group. Because our study reveals serious variation across GMPs, segregation-specific monitoring is necessary to support programs sensitive to local issues and establish necessary benchmarks.

A semi-nested PCR method with increased sensitivity for the specific, direct detection of Salmonella enterica strains in poultry ectoparasites.

The darkling beetle, Alphitobius diaperinus, and the poultry red mite, Dermanysuss gallinae are among the most common pests of poultry farms. Both pests can be carriers and reservoirs of various pathogens including zoonotic ones like Salmonella. Salmonellosis is one of the most common foodborne diseases reported in the EU. We developed a semi-nested PCR method for the direct detection of Salmonella enterica. When testing the specificity of the novel PCR, we successfully detected various S. enterica strains, whereas Escherichia coli and Citrobacter strains gave negative results. The authenticity of the PCR products was confirmed by DNA sequencing. The sensitivity of the semi-nested PCR was tested on serial dilution of bacterial cultures and extracted DNA. We found our new method more sensitive than the previous PCRs. We also screened ectoparasite samples, collected from a poultry farm in Hungary, and three out of the eight samples were positive for S. Enteritidis. This novel PCR seems suitable for the detection of S. enterica strains in poultry ectoparasites without the need of sample pre-enrichment.

Isolation and Characterisation of Electrogenic Bacteria from Mud Samples.

To develop efficient microbial fuel cell systems for green energy production using different waste products, establishing characterised bacterial consortia is necessary. In this study, bacteria with electrogenic potentials were isolated from mud samples and examined to determine biofilm-formation capacities and macromolecule degradation. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry identifications have revealed that isolates represented 18 known and 4 unknown genuses. They all had the capacities to reduce the Reactive Black 5 stain in the agar medium, and 48 of them were positive in the wolfram nanorod reduction assay. The isolates formed biofilm to different extents on the surfaces of both adhesive and non-adhesive 96-well polystyrene plates and glass. Scanning electron microscopy images revealed the different adhesion potentials of isolates to the surface of carbon tissue fibres. Eight of them (15%) were able to form massive amounts of biofilm in three days at 23 °C. A total of 70% of the isolates produced proteases, while lipase and amylase production was lower, at 38% and 27% respectively. All of the macromolecule-degrading enzymes were produced by 11 isolates, and two isolates of them had the capacity to form a strong biofilm on the carbon tissue one of the most used anodic materials in MFC systems. This study discusses the potential of the isolates for future MFC development applications.

Comparative Study on Grape Berry Anthocyanins of Various Teinturier Varieties.

The red-fleshed grape cultivars, called teinturier or dyer grapes, contain anthocyanins in both the skin and flesh. These phenolic compounds exhibit excellent coloring ability, and as antioxidants, they are important bioactive compounds in food crops. In this work, anthocyanin patterns of grape berries of fifteen teinturier varieties collected from the gene bank located at Pécs in the southwest of Hungary were compared. Anthocyanin profiles of numerous varieties originating from Hungary such as 'Bíborkadarka', 'Kármin', 'Kurucvér', and 'Turán' are reported for the first time. Anthocyanins extracted separately from the skin and juice were analyzed using high-performance liquid chromatography coupled with a photodiode array detector. For the identification of compounds, high-resolution orbitrap mass spectrometry was used. All in all, twenty-one anthocyanins were identified and quantified. We found that anthocyanin patterns differed significantly in the skin and juice for all investigated cultivars. For Vitis vinifera varieties, the predominant anthocyanin in the skin was malvidin-3-O-glucoside, while the main pigment in the juice was peonidin-3-O-glucoside. For the first time, a significant amount of diglucosides was detected in two Vitis Vinifera cultivars with a direct relationship. In general, the pigment composition of the skin was much more complex than that of the juice. The comparative study with presented patterns gives valuable and beneficial information from a chemotaxonomical point of view. Our results also help to choose the appropriate teinturier varieties with the desired anthocyanins for food coloring or winemaking purposes.

Phase-Selective Synthesis of Anatase and Rutile TiO2 Nanocrystals and Their Impacts on Grapevine Leaves: Accumulation of Mineral Nutrients and Triggering the Plant Defense.

Titanium dioxide nanocrystals (TiO2 NCs), through their photocatalytic activity, are able to generate charge carriers and induce the formation of various reactive oxygen species (ROS) in the presence of O2 and H2O. This special feature makes TiO2 an important and promising material in several industrial applications. Under appropriate antioxidant balancing, the presence of ROS is crucial in plant growth and development, therefore, the regulated ROS production through the photocatalytic activity of TiO2 NCs may be also exploited in the agricultural sector. However, the effects of TiO2 NCs on plants are not fully understood and/or phase-pure TiO2 NCs are rarely used in plant experiments. In this work, we present a phase-selective synthesis of TiO2 NCs with anatase and rutile crystal phases. The nanomaterials obtained were characterized by means of X-ray diffraction (XRD), transmission electron microscopy (TEM), diffuse reflectance UV-Vis spectroscopy, and electron paramagnetic resonance spectroscopy (EPR). In field experiments, Vitis vinifera cv. Cabernet Sauvignon leaves developed under natural sunlight were treated with aqueous dispersions of TiO2 NCs at concentrations of 0.001, 0.01, 0.1, and 1 w/v%. The effect of the applied nanocrystals was characterized via leaf photochemistry, mineral nutrient contents, and pyridoxine levels. We found that stress responses of grapevine to anatase and rutile NCs treatments are different, which can be related to the different ROS profiles of the two polymorphs. Our results indicate that TiO2 NCs may be utilized not only for direct pathogen inactivation but also for eliciting plant defense mechanisms.

COVID-19 vaccination coverage in deprived populations living in segregated colonies: A nationwide cross-sectional study in Hungary.

The segregated colonies (SCs) in Hungary are populated mainly but not exclusively by Roma. Their health care use is restricted in many respects. It has not been studied yet, whether fair COVID-19 vaccination coverage achieved in Hungary is accompanied with fair effectiveness in SCs. Using census data, the vaccination coverage in SCs and the complementary areas (CAs) in the same settlements of the country was determined. To describe the settlement level differences, the vaccination coverage (until June 30, 2021) in SCs were compared to those in CAs by age, sex, and eligibility for exemption certificate standardized measures. Aggregating settlement level data, the level of geographic discrimination in Hungary was also determined. According to nationwide aggregates, crude vaccination coverage was significantly lower in SCs (40.05%, 95% CI 39.87%-40.23%) than in CAs (65.42%, 95% CI 65.37%-65.46%). The relative standardized vaccination coverage was 0.643 (95% CI 0.639-0.647) in SCs. A total of 437 of the 938 investigated settlements showed significant local vaccination disparities. Hungarian citizens living in SCs, mainly of Roma ethnicity, are a distinct high-risk group. Special intervention adapted to SCs is needed to mitigate inequality in vaccination coverage and further consequences of the pandemic.

Correlations between Total Antioxidant Capacity, Polyphenol and Fatty Acid Content of Native Grape Seed and Pomace of Four Different Grape Varieties in Hungary.

Grape pomace is a valuable source of various bioactive compounds such as plant-derived polyphenols and polyunsaturated fatty acids (PUFAs). The commercial demand of grape skin and seed powders as nutraceuticals is still growing. However, no distinction is currently made between unfermented native grape seed and grape seed pomace powders regarding their antioxidant activities. Our aim was to find the relationship between the polyphenol and fatty acid content as well as the antioxidant capacity of native and fermented grape seeds of four different grape varieties harvested in the Villány wine region. According to our results, none of the three investigated polyphenols (resveratrol, rutin, quercetin) could be detected in native grape seed samples in correlation with their significantly lower total antioxidant capacities compared to fermented seed samples. Pinot Noir (PN) grape seed pomace samples with the highest resveratrol and oil content showed significantly higher total antioxidant capacity than Cabernet Sauvignon (CS), Syrah (S) and Blue Portugal (BP) samples. Based on the statistical analysis, positive correlation was found between the fatty acid content and the resveratrol concentration in the pomace samples of different grape varieties. In contrast, rutin concentrations were negatively proportional to the fatty acid content of the fermented samples. No significant correlation was found considering the quercetin content of the samples. According to our findings, grape pomace seems a more promising source in the production of nutraceuticals, since it contains polyphenols in higher concentration and exerts significantly higher antioxidant activity than native grape seeds.

Infectious Bronchitis Hatchery Vaccination: Comparison between Traditional Spray Administration and a Newly Developed Gel Delivery System in Field Conditions.

The control of infectious bronchitis (IB) is essential in intensive broiler production and is pursued through strict biosecurity and mass vaccination. Despite effective and routinely adopted, hatchery spray vaccination has been hypothesized to affect chicks' body temperature and wellbeing. Recently, gel administration has been proposed as an alternative and proved feasible in experimental settings. In this study, IBV spray and gel vaccination methods were compared in field conditions. One hundred birds from the same hatch were enrolled in the study and vaccinated, half by spray and half by gel, with 793B and Mass vaccines. After vaccination, rectal temperature was measured and vaccine intake assessed. The two groups were housed for 35 days in separate pens and swabs and blood samples were collected at multiple time points for genotype-specific molecular analyses and serology, respectively. The temperature was significantly lower in spray-vaccinated chicks 10 min and an hour after administration. A similar trend in 793B titres was observed in both groups, while the Mass vaccine was detected later but persisted longer in gel-vaccinated chicks. No differences were observed in mean antibody titres. Compared to spray, gel administration appears equally effective and less impactful on body temperature, thus supporting its application for IBV vaccination.

Antimicrobial Efficacy and Spectrum of Phosphorous-Fluorine Co-Doped TiO2 Nanoparticles on the Foodborne Pathogenic Bacteria Campylobacter jejuni, Salmonella Typhimurium, Enterohaemorrhagic E. coli, Yersinia enterocolitica, Shewanella putrefaciens, Listeria monocytogenes and Staphylococcus aureus.

Contamination of meats and meat products with foodborne pathogenic bacteria raises serious safety issues in the food industry. The antibacterial activities of phosphorous-fluorine co-doped TiO2 nanoparticles (PF-TiO2) were investigated against seven foodborne pathogenic bacteria: Campylobacter jejuni, Salmonella Typhimurium, Enterohaemorrhagic E. coli, Yersinia enterocolitica, Shewanella putrefaciens, Listeria monocytogenes and Staphylococcus aureus. PF-TiO2 NPs were synthesized hydrothermally at 250 °C for 1, 3, 6 or 12 h, and then tested at three different concentrations (500 µg/mL, 100 µg/mL, 20 µg/mL) for the inactivation of foodborne bacteria under UVA irradiation, daylight exposure or dark conditions. The antibacterial efficacies were compared after 30 min of exposure to light. Distinct differences in the antibacterial activities of the PF-TiO2 NPs, and the susceptibilities of tested foodborne pathogenic bacterium species were found. PF-TiO2/3 h and PF-TiO2/6 h showed the highest antibacterial activity by decreasing the living bacterial cell number from ~106 by ~5 log (L. monocytogenes), ~4 log (EHEC), ~3 log (Y. enterolcolitca, S. putrefaciens) and ~2.5 log (S. aureus), along with complete eradication of C. jejuni and S. Typhimurium. Efficacy of PF-TiO2/1 h and PF-TiO2/12 h NPs was lower, typically causing a ~2-4 log decrease in colony forming units depending on the tested bacterium while the effect of PF-TiO2/0 h was comparable to P25 TiO2, a commercial TiO2 with high photocatalytic activity. Our results show that PF-co-doping of TiO2 NPs enhanced the antibacterial action against foodborne pathogenic bacteria and are potential candidates for use in the food industry as active surface components, potentially contributing to the production of meats that are safe for consumption.

Effects of heat stress on the immune responses of chickens subjected to thermal manipulation in the pre-hatch period.

Heat stress affects the performance of poultry species and also induces immunosuppression. Chickens can be treated by thermal conditioning to have better heat stress tolerance. Our purpose was to determine the effect of acute heat stress on the immune response, i.e. antibody production against Newcastle disease virus (NDV) and change in the proportion of leukocyte components, in chicks subjected to prenatal heat conditioning. Eighty as-hatched broiler chicks from the same parent stock were used: control (40 chicks incubated at 36.7 °C from days 18-20 of embryonic life) and thermally manipulated (TM) (40 chicks incubated at 38.4 °C from day 18-20 of embryonic life; 4 h/day). The chickens were exposed to heat stress: at day 19 (31 °C/8 h) and at day 35 (32 °C/10 h). The first heat stress (day 19) decreased the lymphocyte counts and significantly increased the heterophil counts (P < 0.05) in both treatments (from 34.25 to 55% in the controls and from 37 to 60.06% in the TM chicks). The second heat stress (day 35) did not alter the heterophil and lymphocyte profiles of the chickens. Before the heat stress, all of the chickens (control and TM) presented the same positive antibody titres to NDV vaccination. After the first heat stress, 50% of the control samples and 40% of samples from the TM chickens were negative. After the second heat stress, 80% of the TM samples were negative.

Is Prescription Nonredemption a Source of Poor Health Among the Roma? Cross-Sectional Analysis of Drug Consumption Data From the National Health Insurance Fund of Hungary.

Background: The health status of the Roma is inferior to that of the general population. The causes of poor health among this population are still ambiguous, but they include low utilization of healthcare services. Our study aimed to investigate prescription redemptions in segregated Roma colonies (SRC) where the most disadvantaged quartile of Roma people are living. Methods: A cross-sectional study was carried out with data obtained from the National Institute of Health Insurance Fund Management in the settlements belonging to the study area of the "Public Health-Focused Model Program for Organizing Primary Care Services." The study included 4,943 residents of SRC and 62,074 residents of the complementary area (CA) of the settlements where SRC were located. Crude and age- and sex-standardized redemption ratios for SRC and CA were calculated for each Anatomic Therapeutic Chemical (ATC) group and for the total practice by ATC group. Standardized relative redemptions (RR) with 95% confidence intervals were calculated for SRC, with CA as a reference. Results: The crude redemption ratios were 73.13% in the SRC and 71.15% in the CA. RRs were higher in the SRC than in the CA for cardiovascular, musculoskeletal system, and alimentary tract and metabolism drugs (11.5, 3.7, and 3.5%, respectively). In contrast, RRs were lower in the SRC than in the CA for anti-infective agents (22.9%) due to the poor redemption of medicines prescribed for children or young adults. Despite the overall modest differences in redemption ratios, some ATC groups showed remarkable differences. Those include cardiovascular, alimentary and musculoskeletal drugs. Conclusion: Redemption of prescriptions was significantly higher among Roma people living in SRC than among those living in CA. The better redemption of cardiovascular and alimentary tract drugs was mainly responsible for this effect. These findings contradict the stereotype that the Roma do not use health services properly and that prescription non-redemption is responsible for their poor health.

Self-Declared Roma Ethnicity and Health Insurance Expenditures: A Nationwide Cross-Sectional Investigation at the General Medical Practice Level in Hungary.

The inevitable rising costs of health care and the accompanying risk of increasing inequalities raise concerns. In order to make tailored policies and interventions that can reduce this risk, it is necessary to investigate whether vulnerable groups (such as Roma, the largest ethnic minority in Europe) are being left out of access to medical advances. Objectives: The study aimed to describe the association between general medical practice (GMP) level of average per capita expenditure of the National Health Insurance Fund (NHIF), and the proportion of Roma people receiving GMP in Hungary, controlled for other socioeconomic and structural factors. Methods: A cross-sectional study that included all GMPs providing care for adults in Hungary (N = 4818) was conducted for the period 2012-2016. GMP specific data on health expenditures and structural indicators (GMP list size, providing care for adults only or children also, type and geographical location of settlement, age of GP, vacancy) for secondary analysis were obtained from the NHIF. Data for the socioeconomic variables were from the last census. Age and sex standardized specific socioeconomic status indicators (standardized relative education, srEDU; standardized relative employment, srEMP; relative housing density, rHD; relative Roma proportion based on self-reported data, rRP) and average per capita health expenditure (standardized relative health expenditure, srEXP) were computed. Multivariate linear regression model was applied to evaluate the relationship of socioeconomic and structural indicators with srEXP. Results: The srEDU had significant positive (b = 0.199, 95% CI: 0.128; 0.271) and the srEMP had significant negative (b = -0.282, 95% CI: -0.359; -0.204) effect on srEXP. GP age > 65 (b = -0.026, 95% CI: -0.036; -0.016), list size <800 (b = -0.043, 95% CI: -0.066; -0.020) and 800-1200 (b = -0.018, 95% CI: -0.031; -0.004]), had significant negative association with srEXP, and GMP providing adults only (b = 0.016, 95% CI: 0.001;0.032) had a positive effect. There was also significant expenditure variability across counties. However, rRP proved not to be a significant influencing factor (b = 0.002, 95% CI: -0.001; 0.005). Conclusion: As was expected, lower education, employment, and small practice size were associated with lower NHIF expenditures in Hungary, while the share of self-reported Roma did not significantly affect health expenditures according to our GMP level study. These findings do not suggest the necessity for Roma specific indicators elaborating health policy to control for the risk of widening inequalities imposed by rising health expenses.

Photocatalytic Inactivation of Plant Pathogenic Bacteria Using TiO2 Nanoparticles Prepared Hydrothermally.

Exploitation of engineered nanomaterials with unique properties has been dynamically growing in numerous fields, including the agricultural sector. Due to the increasing resistance of phytopathogenic microbes, human control over various plant pathogens in crop production is a big challenge and requires the development of novel antimicrobial materials. Photocatalytic active nanomaterials could offer an alternative solution to suppress the plant pathogens. In this work, titanium dioxide nanoparticles (TiO2 NPs) with high photocatalytic activity were synthesized by hydrothermal post-treatment of amorphous titania at different temperatures (250 °C or 310 °C) without using any additives or doping agents. The obtained samples were investigated through X-ray diffraction, N2-sorption measurements, diffuse reflectance UV-Vis spectroscopy, transmission electron microscopy, electron paramagnetic resonance spectroscopy, and X-ray photoelectron spectroscopy. The applied hydrothermal treatment led to the formation of TiO2 nanocrystallites with a predominant anatase crystal phase, with increasing crystallinity and crystallite size by prolonging treatment time. The photocatalytic activity of the TiO2 NPs was tested for the photo-degradation of phenol and applied for the inactivation of various plant pathogens such as Erwinia amylovora, Xanthomonas arboricola pv. juglandis, Pseudomonas syringae pv. tomato and Allhorizobium vitis. The studied bacteria showed different susceptibilities; their living cell numbers were quickly and remarkably reduced by UV-A-irradiated TiO2 NPs. The effectiveness of the most active sample prepared at 310 °C was much higher than that of commercial P25 TiO2. We found that fine-tuning of the structural properties by modulating the time and temperature of the hydrothermal treatment influenced the photocatalytic properties of the TiO2 NPs considerably. This work provides valuable information to the development of TiO2-based antimicrobial photocatalysts.

Age- and season-dependent pattern of flavonol glycosides in Cabernet Sauvignon grapevine leaves.

Flavonols play key roles in many plant defense mechanisms, consequently they are frequently investigated as stress sensitive factors in relation to several oxidative processes. It is well known that grapevine (Vitis vinifera L.) can synthesize various flavonol glycosides in the leaves, however, very little information is available regarding their distribution along the cane at different leaf levels. In this work, taking into consideration of leaf position, the main flavonol glycosides of a red grapevine cultivar (Cabernet Sauvignon) were profiled and quantified by HPLC-DAD analysis. It was found that amount of four flavonol glycosides, namely, quercetin-3-O-galactoside, quercetin-3-O-glucoside, kaempferol-3-O-glucoside and kaempferol-3-O-glucuronide decreased towards the shoot tip. Since leaf age also decreases towards the shoot tip, the obtained results suggest that these compounds continuously formed by leaf aging, resulting in their accumulation in the older leaves. In contrast, quercetin-3-O-glucuronide (predominant form) and quercetin-3-O-rutinoside were not accumulated significantly by aging. We also pointed out that grapevine boosted the flavonol biosynthesis in September, and flavonol profile differed significantly in the two seasons. Our results contribute to the better understanding of the role of flavonols in the antioxidant defense system of grapevine.

Determinants of Primary Nonadherence to Medications Prescribed by General Practitioners Among Adults in Hungary: Cross-Sectional Evaluation of Health Insurance Data.

Background: Primary nonadherence to prescribed medications occurs when patients do not fill or dispense prescriptions written by healthcare providers. Although it has become an important public health issue in recent years, little is known about its frequency, causes, and consequences. Moreover, the pattern of risk factors shows remarkable variability across countries according to the published results. Our study aimed to assess primary nonadherence to medications prescribed by general practitioners (GPs) and its associated factors among adults in Hungary for the period of 2012-2015. Methods: Data on all general medical practices (GMPs) of the country were obtained from the National Health Insurance Fund and the Central Statistical Office. The ratio of the number of dispensed medications to the number of prescriptions written by a GP for adults was used to determine the medication adherence, which was aggregated for GMPs. The effect of GMP characteristics (list size, GP vacancy, patients' education provided by a GMP, settlement type [urban or rural], and geographical location [by county] of the center) on adherence, standardized for patients' age, sex, and eligibility for an exemption certificate, were investigated through generalized linear regression modeling. Results: A total of 281,315,386 prescriptions were dispensed out of 438,614,000 written by a GP. Overall, 64.1% of prescriptions were filled. According to the generalized linear regression coefficients, there was a negative association between standardized adherence and urban settlement type (b = -0.099, 95%CI = -0.103 to -0.094), higher level of education (b = -0.440, 95%CI = -0.468 to -0.413), and vacancy of the general practices (b = -0.193, 95%CI = -0.204 to -0.182). The larger GMP size proved to be a risk factor, and there was a significant geographical inequality for counties as well. Conclusions: More than one-third of the written prescriptions of GPs for adults in Hungary were not dispensed. This high level of nonadherence had great variability across GMPs, and can be explained by structural characteristics of GMPs, the socioeconomic status of patients provided, and the quality of cooperation between patients and GPs. Moreover, our findings suggest that the use of the dispensed-to-prescribed medication ratio in routine monitoring of primary health care could effectively support the necessary interventions.

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services.

This study was part of monitoring an intervention aimed at developing a general practitioner cluster (GPC) model of primary healthcare (PHC) and testing its effectiveness in delivering preventive services integrated into the PHC system. The aim was to demonstrate whether GPC operation could increase the percentage of drugs actually dispensed. Using national reference data of the National Health Insurance Fund for each anatomical-therapeutic chemical classification ATC group of drugs, dispensed-to-prescribed ratios standardized (sDPR) for age, sex, and exemption certificate were calculated during the first quarter of 2012 (before-intervention) and the third quarter of 2015 (post-intervention). The after-to-before ratios of the sDPR as the relative dispensing ratio (RDR) were calculated to describe the impact of the intervention program. The general medication adherence increased significantly in the intervention area (RDR = 1.064; 95% confidence interval (CI): 1.054-1.073). The most significant changes were observed for cardiovascular system drugs (RDR = 1.062; 95% CI: 1.048-1.077) and for alimentary tract and metabolism-specific drugs (RDR = 1.072; 95% CI: 1.049-1.097). The integration of preventive services into a PHC without any specific medication adherence-increasing activities is beneficial for medication adherence, especially among patients with cardiovascular, alimentary tract, and metabolic disorders. Monitoring the percentage of drugs actually dispensed is a useful element of PHC-oriented intervention evaluation frames.

Factors Associated with Practice-Level Performance Indicators in Primary Health Care in Hungary: A Nationwide Cross-Sectional Study.

The performance of general practitioners (GPs) is frequently assessed without considering the factors causing variability among general medical practices (GMPs). Our cross-sectional national-based study was performed in Hungary to evaluate the influence of GMP characteristics on performance indicators. The relationship between patient's characteristics (age, gender, education) and GMP-specific parameters (practice size, vacancy of GP's position, settlement type, and county of GMP) and the quality of care was assessed by multilevel logistic regression models. The variations attributable to physicians were small (from 0.77% to 17.95%). The education of patients was associated with 10 performance indicators. Practicing in an urban settlement mostly increased the quality of care for hypertension and diabetes care related performance indicators, while the county was identified as one of the major determinants of variability among GPs' performance. Only a few indicators were affected by the vacancy and practice size. Thus, the observed variability in performance between GPs partially arose from demographic characteristics and education of patients, settlement type, and regional location of GMPs. Considering the real effect of these factors in evaluation would reflect better the personal performance of GPs.

The impact of general practitioners' gender on process indicators in Hungarian primary healthcare: a nation-wide cross-sectional study.

OBJECTIVES: The objectives of our study were (1) to investigate the association between gender of the general practitioner (GP) and the quality of primary care in Hungary with respect to process indicators for GP performance and (2) to assess the size of the gender impact. STUDY DESIGN: A nation-wide cross-sectional study was performed in 2016. SETTING AND PARTICIPANTS: The study covered all general medical practices in Hungary (n=4575) responsible for the provision of primary healthcare (PHC) for adults. All GPs in their private practices are solo practitioners. MAIN OUTCOME MEASURES: Multilevel logistic regression models were used to analyse the association between GP gender and process indicators of PHC, and attributable proportion (AP) was calculated. RESULTS: 48% of the GPs (n=2213) were women in the study. The crude rates of care provided by female GPs were significantly higher for seven out of eight evaluated indicators than those provided by male GPs. Adjusted for practice, physician and patient factors, GP gender was associated with the haemoglobin A1c (HbA1c) measurement: OR=1.18, 95% CI (1.14 to 1.23); serum creatinine measurement: OR=1.14, 95% CI (1.12 to 1.17); lipid measurement: OR=1.14, 95% CI (1.11 to 1.16); eye examination: OR=1.06, 95% CI (1.03 to 1.08); mammography screening: OR=1.05, 95% CI (1.03 to 1.08); management of patients with chronic obstructive pulmonary disease: OR=1.05, 95% CI (1.01 to 1.09) and the composite indicator: OR=1.08, 95% CI (1.07 to 1.1), which summarises the number of care events and size of target populations of each indicator. The AP at the specific indicators varied from 0.97% (95% CI 0.49% to 1.44%) of influenza immunisation to 8.04% (95% CI 7.4% to 8.67%) of eye examinations. CONCLUSION: Female GP gender was an independent predictor of receiving higher quality of care. The actual size of the gender effect on the quality of services seemed to be notable. Factors behind the gender effect should receive more attention in quality improvement particularly in countries where the primary care is organised around solo practices.

Workforce crisis in primary healthcare worldwide: Hungarian example in a longitudinal follow-up study.

OBJECTIVE: The study was designed to explore the development of the general practitioner (GP) shortage in primary care and its characteristics in Hungary. DESIGN: Longitudinal follow-up study over the decade 2007-2016. METHODS: Analyses were performed on changes in number, age and sex of GPs by practice type (adult, paediatric and mixed), as well as on their geographical distribution and migration between areas characterised by deprivation index (DI) at municipality level. The association between deprivation and vacancy for GPs was studied by risk analysis. The number of population underserved was defined by DI quintile. SETTING AND SUBJECTS: The study involved all general practices and GPs in the period examined. MAIN OUTCOME MEASURE: It is showed that the number of general practices with unfilled GP posts was increasing exponentially, mainly in the most deprived areas of the country. RESULTS: A decrease in the number of GPs in all types of practices, especially in mixed (by 7.7%; p<0.001) and paediatric (by 6.5%; p<0.001) ones, was shown; the number of adult practices with unfilled GP posts doubled, while the number of paediatric practices with a vacancy for a paediatrician more than tripled. The average age of GPs was increased by 3.7 years (p<0.001) in adult, by 5.4 years (p<0.001) in paediatric and by 4.2 years (p<0.001) in mixed practices. In 2007, 52.27% (95% CI 51.03 to 53.5) of the GPs were women, and this rate increased to 56.19% (95% CI 54.93 to 57.44) by the end of the decade. An exponential association between relative vacancy rate and deprivation was confirmed. As a result of the migration of GPs, in the most deprived areas, the number of GPs decreased by 8.43% (95% CI 5.86 to 10.99). CONCLUSIONS: The workforce crisis in Hungarian primary care is progressively deepening and resulting in more severe inequity in access to healthcare.