Smoking and lung cancer mortality in Malta

In the European region, tobacco is responsible for 16% of all deaths in adults and 12% of all deaths in the Maltese population. While locally, fewer adult females smoke when compared to males, there is an increasing trend of smoking amongst females whilst in males we are seeing a decline. Also, while mortality rates in males from lung cancer in Malta are much higher than in females, a downward trend is being observed in males, whilst in females mortality rates are showing a slowly rising trend.peer-reviewe

Recreational drug use and the emerging challenges of psychoactive substances in Malta : a case series

Introduction: Recreational drug-related hospital admissions, excluding alcohol, appeared to be relatively constant in Mater Dei Hospital (MDH), Malta’s sole public, acute general hospital. While ‘classical’ recreational drugs such as cocaine, heroin and Methylenedioxymethamphetamine (MDMA) were always seen as the main culprits, intoxications secondary to novel psychoactive substances (NPS) have recently emerged in MDH. The aim of this study was to determine the challenges of recreational drug intoxication, including NPS, in MDH. Methods: All the MDH admissions secondary to recreational drug intoxication between 2010 and 2015 were investigated. MDH clinical performance unit (CPU), hospital data files, hospital discharge letters and the hospital database software system were utilised for data collection. Intoxications associated with self-harm, trauma and lone alcohol ingestions were excluded. Results: 286 patients were admitted to MDH with recreational drug intoxication between 2010-2015, with a peak of 71 patients in 2015. 78.3% were males and the median age was 26 years. While 79% of the admissions were Maltese nationals, there was a surge in foreigner admissions, from 11.8% between 2010-2012 to 28.3% between 2013-2015 (p<0.001). Admissions occurred mostly in spring and summer, on Saturday or Sunday, and at night. 52.4% of admissions were acutely confused. Ethanol co-ingestion (40.9%) and polydrug use (39.9%) were common in these admissions. 16% needed admission to critical care. 91.3% admissions were secondary to ‘Classical’ recreational drugs, mostly heroin and cocaine. In 2015, 36.6% of admissions were secondary to NPS, mostly synthetic cannabinoids (SCRA). SCRA admissions were associated with severe sympathomimetic and neuropsychiatric features. An SCRA toxidrome mnemonic (MEET_SCRA) is proposed from the most common features of lone intoxications. Conclusion: Recreational drugs were associated with significant hospital burden, with NPS representing a new threat to MDH and Maltese public health. The toxidrome mnemonic MEET_SCRA could potentially aid in the identification of SCRA intoxications.peer-reviewe

Does aortic valve replacement restore normal life expectancy? A twenty-year relative survival study

Background: This 20-year relative survival study investigates life expectancy in defined age cohorts and evaluates the role of patient, procedural and peri-operative variables on absolute survival after aortic valve replacement. Methods: Absolute long-term survival variance was calculated using Cox regression analysis in 585 consecutive aortic valve replacement patients. Relative survival curves in defined age groups were constructed using age- and gender-matched controls. Results: There were 12 peri-operative deaths (2.1%), and 11 further deaths (1.9%) during the first year. 154 patients (26.3%) died subsequently and 408 patients (69.7%) were alive after 20 years. Relative survival increased with age: in patients over 68 survival was equivalent to an age- and gender-matched population. Patient risk indicators for decreased absolute survival included age, Parsonnet score, additive and logistic EuroSCORE, and for increased absolute survival included weight, body surface area, and stroke volume. Procedural risk indicators for decreased absolute survival included bypass time, use of a tissue valve, and prosthesis-patient mismatch with size 19 valves, and for an increased absolute survival included use of a mechanical valve. Postoperative risk indicators for decreased absolute survival included ITU stay, ventilation time, transfusion, haemorrhage volume and new-onset atrial fibrillation/flutter. Strong risk indicators included intra-aortic balloon pump use, and dialysis. Conclusions: Patients over 68 years discharged from hospital after aortic valve replacement had a similar 10-year survival as an age- and gendermatched population. In this age cohort surgery restored the patient’s normal life expectancy.peer-reviewe

Population-level cure of colorectal cancer in Malta: An analysis of patients diagnosed between 1995 and 2004.

AIM: The aim of this study was to estimate the population-level 'cure' of Maltese colorectal cancer patients diagnosed between 1995 and 2004, and to estimate the median survival time for the 'uncured' patients. METHODS AND STUDY POPULATION: Analysis was conducted on 1470 cases registered by the Malta National Cancer Register between 1995 and 2004 and followed up to end of 2010. The mean age of the patients was 66.4 (95%CI 65.8-67.1), and the number of men and women were equal. Background mortality for 1995-2010 was extracted from publicly available life tables. A mixture model with Weibull survival distribution and identity link was used to model 'cure'. RESULTS: The overall 'cured' proportion for the patients diagnosed in 1995-1999 was 45.3% (95%CI 40.2-50.5) while the 'cured' proportion for the patients diagnosed in 2000-2004 was 52.3% (95%CI 47.2-57.5). Median survival time for the 'uncured' patients increased in the second calendar period from 1.25 years (95%CI 1.04-1.45) to 1.42 years (95%CI 1.15-1.76). CONCLUSION: In Malta, as in the rest of Europe, improvements have been made in short- and long-term survival over the 15-year period under study. To continue this improvement, differences by age that still persist must be investigated and efforts focused to reduce any gaps between Malta and other European countries

Business process management in health care : current challenges and future prospects

The emphasis of performance management in health care is shifting from output or outcome-based to a system-based approach. In particular, clinicians and managers are re-focusing their attention on processes so as to achieve better health system performance, as a reaction to the financial crisis. Health care management is increasingly applying systems thinking and business process management (BPM) as philosophies, which have proved to make a difference in organizational performance and competitiveness to the industry at large. This commentary provides answers to five questions that emerged through a reflective exercise and use of secondary data sources and informal interviews. These questions are intended to contribute toward better understanding of the meaning and application of BPM by scholars and practitioners in health care management. The questions are as follows: What is BPM and is it relevant to health care? Has BPM been extensively applied to health care? Why focus on quality in health care delivery? What are the current challenges of health care and can BPM help? What role BPM will play in future to facilitate effective health care management?peer-reviewe

Measuring health inequalities in Malta: Development and application of a small area-based deprivation index

Background - Improvement in population health requires that health systems focus on social determinants as important risk factors. Despite some limitations, small area-based deprivation indices have been useful in the analysis of health inequalities. These indices can be linked to data sources through small area-based geographical information. The aim of this thesis was to develop and validate a small area-based deprivation index for Malta using census data and apply it to the analysis of health inequalities. Methods - Data from two censuses were used to create the index. Nineteen area level items were considered. After Z-standardisation, principal component analysis was used for item reduction and a weighted additive score was constructed. Quintiles of deprivation from least to most deprived were produced. The index was applied to the analysis of deprivation gradients for mortality and cancer incidence using age-standardised rates. The Relative Index of Inequality (RII) was estimated. Multi-level logistic regression models were used to analyse the association between individual socioeconomic factors and the area deprivation measure on two self-reported health outcomes and mortality. Results - The final index contained five items within the domains of education, employment and living conditions. Premature mortality rates declined between the two periods, however the linear gradient for premature mortality by deprivation quintile, increased. This was most notable for males in the most deprived areas, where the premature mortality rate in the most recent period increased. Results for old-age mortality were less consistent. The relationship between deprivation and cancer incidence was not consistent, with negative and positive gradients observed for different sites. Results for bronchus-lung cancer incidence presented the strongest deprivation gradient. In the multi-level models, a gradient was still seen with increasing deprivation for all health outcomes, though the odds were attenuated when including individual predictors. The strongest relationships were maintained for the most deprived quintile. Discussion - The small area-based deprivation index presented deprivation gradients for mortality and cancer incidence. Even when including individual predictors of socioeconomic status, the area measure still contributed to the analysis of health inequalities. The findings were generally in line with what was found elsewhere. The index developed has wider implications for research, evidence-based policy making and practice in Malta. Conclusion- Area-based indices assign a level of deprivation to an area and not individuals, and thus may be prone to ecological fallacy. Despite this, there is continued value in their use in health inequalities research

Utilisation of gp services in the private and public sector

Aims: 1) To outline the overall rates of private and public GP consultation 2) To compare usage between the sectors 3) To outline any health inequalities within these two sectorspeer-reviewe

Post-surgery length of stay using multi-criteria decision-making tool

Purpose Length of stay (LOS) in hospital after surgery varies for each patient depending on surgeon’s decision that considers criticality of the surgery, patient’s conditions before and after surgery, expected time to recovery and experience of the surgeon involved. Decision on patients’ LOS at hospital post-surgery affects overall healthcare performance as it affects both cost and quality of care. The purpose of this paper is to develop a model for deriving the most appropriate LOS after surgical interventions. Design/methodology/approach The study adopts an action research involving multiple stakeholders (surgeon, patients/patients’ relatives, hospital management and other medics). First, a conceptual model is developed using literature and experts’ opinion. Second, the model is applied in three surgical interventions in a public hospital in Malta to demonstrate the effectiveness of the model. Third, the policy alternatives developed are compared to a selection of current international standards for each surgical intervention. The proposed model analyses three LOS threshold policies for three procedures using efficiency and responsiveness criteria. The entire analysis is carried out using 325 randomly selected patient files along with structured interactions with more than 50 stakeholders (surgeon, patients/patients’ relatives, hospital management and other medics). A multiple criteria decision-making method is deployed for model building and data analysis. The method involves combining the analytic hierarchy process (AHP) for verbal subjective judgements on prioritizing the four predictors of surgical LOS—medical, financial, social and risk, with pairwise comparisons of the sub-criteria under each criterion in line with the concerned interventions—the objective data of which are obtained from the patients’ files. Findings The proposed model was successfully applied to decide on the best policy alternative for LOS for the three interventions. The best policy alternatives compared well to current international benchmarks. Research limitations/implications The proposed method needs to be tested for other interventions across various healthcare settings. Practical implications Multi-criteria decision-making tools enable resource optimization and overall improvement of patient care through the application of a scientific management technique that involves all relevant stakeholders while utilizing both subjective judgements as well as objective data. Originality/value Traditionally, the duration of post-surgery LOS is mainly based on the surgeons’ clinical but also arbitrary decisions, with, as a result, having insufficiently explicable variations in LOS amongst peers for similar interventions. According to the authors’ knowledge, this is the first attempt to derive post-surgery LOS using the AHP, a multiple criteria decision-making method

Narcolepsy, cataplexy, hypocretin and co-existing other health complaints: A review

The presence of cataplexy in people with narcolepsy has a well-documented tight association with very low or non-detectable levels of the central nervous system neuropeptide, hypocretin (also termed orexin) while levels of hypocretin are normal in people with narcolepsy without cataplexy. There is evidence to suggest that hypocretin may have an association with pain, migraines and headaches in people with narcolepsy. However, these studies have not compared findings across narcolepsy with and without cataplexy. Currently, there are no studies published to determine whether pain, migraines and headaches are just common symptoms experienced by all people with narcolepsy or whether the presence of the cataplexy symptom (and thus assumed low levels of hypocretin) exacerbates these symptoms. Also, it is unclear whether general health and wellbeing (including psychological wellbeing) is similarly affected by hypocretin levels, or may be confounded by different levels of other health symptoms, such as pain. This review poses a number of research questions that need to be explored about whether the presence or absence of cataplexy is differentially associated with different types, severity and location of chronic pain; frequency, location and types of migraines and headaches; and general health and wellbeing among people with narcolepsy. A greater understanding of the role of hypocretin in these health complaints could aid in the development of more appropriate treatments for pain, migraines and headaches amongst people with and without narcolepsy

Hypertension in a primary care setting in Buza, Tanzania & Malta

Introduction: Worldwide prevalence of hypertension (HT) in established market economy countries is estimated at 37.4% for males and 37.2% for females. Aim: To identify the frequency of HT in sample populations of Malta and Buza, Tanzania, looking specifically at gender differences, the rate of previous diagnosis and compliance to medication. Methods: A comparative cross-sectional population-based survey to calculate the frequency of hypertension of a sample of the Maltese population reviewed in 2010 and a sample of people reviewed in a primary care medical clinic Buza in that same year. Both samples were statistically matched and compared. Results: Frequency of HT in the Maltese sample was 32.8% (M:F - 32.8:32.8), and compliance rate was 48%. The frequency of HT in the Buza sample was 48.4% (M:F - 47.7:48.9) and the compliance rate was 8%. Frequency of stage II and malignant HT were significantly more prevalent in the Buza population. The frequency of HT increased with age in both populations studied. Conclusions: Prevalence of examined HT in the Maltese sample was higher than the self-reported survey carried out in 2008, but still lower than the Buza sample and within range of the established market economy countries. Education and awareness of HT will increase lifestyle changes and further reduce the frequency of HT and increase the compliance rates in both populations. Hypertension awareness and readily available treatment is a much needed public health service. Furthermore, it is cheap, easy to offer and significantly improves quality of life.peer-reviewe