Factors associated with practice-level performance indicators in primary health care in Hungary: a nationwide cross-sectional study

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

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Factors Associated with Practice-Level Performance Indicators in Primary Health Care in Hungary

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

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Determinants of Primary Nonadherence to Prescribed Medications among Adults in Hungary

Background: Adherence is defined as taking medications as described or prescribed by health care professionals. Adherence is an important notion that reflects the degree to which patients conform or follow instructions and recommendations of health care providers throughout the prescribed treatment course. It involves a retrospective memory for remembering the way the medicines to be used and a prospective memory concerning the time at which the medications to be taken. The adherence process entails three main elements: initiation of therapy; implementation of the therapy as prescribed; and persistence on the given therapy for the desired period of time. Primary nonadherence refers to a situation when people do not dispense the new prescriptions written by their health care providers from the beginning of the treatment course. Although primary adherence to medications is crucial for any successful treatment strategy in both acute and chronic health conditions, less attention has been given to this issue until recently. In fact, little is known about frequency, causes, and consequences of primary nonadherence. In addition, the published literature shows variable impact of risk factors on adherence. Primary nonadherence has not been investigated previously in Hungary at the national level. Objectives: The aim of this study was to (1) estimate primary nonadherence to GMP prescribed medications among adults in Hungary using the WHO key indicator of patient care “percentage of drugs actually dispensed” as a basic concept to quantify the dispensed medications at the period between 2012 and 2015; (2) to determine effects of GMP structure and patient characteristics on adherence; (3) to describe variation of adherence across GMPs; and (4) to test whether operating GPC model for the purpose of organizing and improving effectiveness of PHC implemented in the “Public Health Focused Model Programme for Organising Primary Care Services Backed by a Virtual Care Service Centre” increases the percentage of drugs actually dispensed. Methods: National data on all GMPs were obtained from the National Health Insurance Fund and the Hungarian Central Statistical Office for the period 2012 -2015. The data were aggregated for all running GMPs around the country for all ATC group of drugs. Ratios of dispensed to written (DWRs) prescriptions written by GPs for adults aged 18 years and above were used to determine levels of primary adherence to prescribed medications at the national level. Standardized DWRs (SDWRs) were calculated using the indirect standardization method for age, sex, and eligibility for an exemption certificate. Generalized linear regression modeling was used to identify the major determinants of the SDWRs while controlling for the time. Characteristics of GMPs including patient education obtained from the GMPs, vacancy of the GMPs, type of settlement as urban or rural, county list size according to the number of adults receiving health care, and geographical location of the county were the investigated determinants in the regression model. The data analyses were completed using SPSS version 20. To evaluate impact of the SHCP, SDWRs were calculated in the first quarter of 2012 (2012Q1 representing before intervention status) and in the third quarter of 2015 (2015Q3 representing post-intervention status). Risk ratios (RR) were estimated by taking after to before ratios for SDWRs along with their corresponding 95% confidence intervals (95%CI). Results: Out of 438,614,000 written prescriptions between 2012 and 2015, 281,315,386 prescriptions were dispensed. Overall, 64.1% of the written prescriptions were dispensed. Based on the generalized linear regression coefficient (b), there was an inverse association between SDWRs and relative education of patients [b=-0.440, 95%CI: -0.468;-0.413], vacancy of the GMPs [b= -0.193, 95%CI: -0.204;-0.182], and living in urban areas [b= -0.099, 95%CI: -0.103;-0.094]. A better SDWRs was noted for GMPs running in a relatively smaller localities [bX-800= 0.052, 95%CI: 0.041; 0.063, b801-1200= 0.031, 95%CI: 0.025; 0.037, b1201-1600= 0.017, 95%CI: 0.013; 0.022] compared to those running in larger localities [b2001-X= -0.014, 95%CI: -0.019;-0.009]. In addition, geographical location of the county was an important determinant. In the intervention area where the SHCP was implemented, SDWRs indicated that overall adherence was generally higher in the intervention area than in Hungary for various ATC groups. SDWR for the entire practice was 1.042 in 2012Q1 and increased to 1.108 after the intervention in 2015Q3. When the RR was calculated for SDWRs, this change was shown to be significant [RR= 1.064; 95%CI: 1.054 - 1.073] indicating an overall improvement of 6.4% in adherence. The excess number of prescriptions dispensed was 5,033 in 2015Q3. The most significant impact observed was on both cardiovascular system drugs [RR= 1.062; 95%CI: 1.048-1.077] and alimentary tract and metabolism drugs [RR=1.072; 95%CI: 1.049-1.097] with 2,143 and 1,001 excess number of dispensed prescriptions, respectively. In addition, significant positive changes were observed for musculoskeletal drugs [RR=1.041; 95%CI: 1.010-1.074], blood and blood-forming organ drugs [RR=1.077; 95%CI: 1.044-1.111], and drugs of the nervous system [RR= 1.082; 95%CI: 1.047-1.118]. Study implications: Nonadherence contributes substantially to poor disease diagnosis. This impact was not investigated in our analysis but expected to be great since only 59.4% of cardiovascular system drugs are actually dispensed although cardiovascular diseases are the leading causes of death and the major determinants of Life expectancy in the European region. In addition, nonadherence results in considerable loss of time, work, capacities and resources of the Hungarian health care system. It may reflect poor patient-physician relationship. Also, the observed variations in adherence among various GMPs reflect various capacities of the GPs in managing and dealing with their customers. Moreover, the study provided evidence on the weak role of GPs in managing clients in urban areas and those with high levels of education. The intensive care given to patients in the SHCP was fruitful in enhancing adherence although increasing adherence was not among objectives of the programme. This probably confirms that improved patient-physician relationship is a cornerstone not only in enhancing adherence but also the overall health status of the population. Use of the WHO indicator percentage of drugs actually dispensed is a good tool for monitoring performance of GMPs and assessment of effectiveness of intervention programmes. Conclusions: About one-third of the prescriptions written by GPs working in PHC were not filled in Hungary indicating an overall alarming high rate of nonadherence. The study also demonstrated a wide variability of adherence across various GMPs. This variation can be attributed to GMPs' structural characteristics including patients’ socioeconomic status, vacancy of GMPs, list size of the county, locality type, and geographic location of the counties and more importantly magnitude of patient-physician cooperation and communication style. The SHCP provided evidence that extension of PHC services to include integrated and preventive services with proper protocol necessary capacities enhanced medication adherence. This improvement was remarkable among adult patients with cardiovascular diseases and alimentary tract and metabolic disorders. The improvement of 6.4% reported in the programme without any specific activity for increasing adherence goes in line with published studies (range 4%-11%) devoted totally to enhance adherence using multifaceted interventions. In addition, our findings proposed that DWRs can be used in routine monitoring of the operation of PHC and support substantial interventions. This finding endorses recommendations of the WHO in using the percentage of drugs actually dispensed in regular monitoring as a key indicator of patient care. Furthermore, measuring DWRs could be a useful indicator of the effectiveness of client- health care professionals’ relationships in PHC

Disability among Palestinian elderly in the occupied Palestinian territory (oPt): prevalence and associated factors

Abstract Background Disability poses an important challenge to countries all over the world since it affects more than 15% of the global population. The disability prevalence is higher in developing countries compared to developed ones. Disability has negative consequences on health, wellbeing, and quality of life. The goal of this study is to assess the prevalence of disability and to determine some of its associated factors among Palestinian elderly in the occupied Palestinian territory (oPt), a country marked by a chronic lack of political, economic, and social stability which affect various aspects of the population’s life. Methods We used data from the Palestinian Central Bureau of Statistics (PCBS) disability survey conducted in 2011 using a nationally representative sample of the Palestinians living in the West Bank (WB) and Gaza Strip (GS). Data were collected using a standardized questionnaire developed and adopted by the World Health Organization (WHO) and the Washington Group (WG) for Disability Statistics, adapted to satisfy the Palestinian context. Results Overall, 31.2% of the Palestinian elderly 60 years and above reported one or more type of disability. Binary logistic regression with disability as the dependent variable showed that older people [OR = 2.88, 95% CI: 2.31–3.60], women [OR = 1.65, 95% CI: 1.33–2.04], illiterate people [OR = 2.37, 95% CI: 1.83–3.06], people reporting small family sizes with 1 to 2 members [OR = 1.69, 95% CI: 1.34–2.14], people who reported that they were not working at the time of the survey [OR = 4.59, 95% CI: 3.13–6.73], and Palestinian refugees [OR = 1.22, 95% CI: 1.04–1.42] were more likely to have a disability. However, residents of the Centre of WB were less likely to have disability compared to residents of the GS [OR = 0.46, 95% CI: 0.37–0.58]. Conclusions The study found a high prevalence of disability among Palestinian elderly, as has been reported by the majority of studies performed in developing countries. However, results indicate that demographic and socioeconomic differences among the disabled should be taken into special consideration in setting policies and practices to improve the health and wellbeing of the disabled

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 eectiveness 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.L

(Re)creations : telling about Iron Age Dan and the Hula Valley

This dissertation suggests alternative ways of thinking about the scales of interpretation in Syro-Palestinian archaeology. It does this by outlining a number of ideas prevalent in what has been called post-processual or interpretive archaeology and looking at ways they could be employed in the Iron Age Hula Valley region. Chief among these are considerations of landscape, ethnography, phenomenology, post-colonialism and narrative. The central site examined is that of Tel Dan and, importantly, an overview of the valley itself and its outstanding features - the lake and swamp - are also considered. The purpose of this thesis is to show that it is possible to write small-scale, even personal narratives, about the way people may have lived at a particular place and time without recourse to the biblical texts. I suggest that the use of such narratives can be used to produce alternative accounts of the past and thus subvert the grand-narratives of the region. The method outlined is as opposed to the large-scale Annalistic approaches which currently predominate. To this end a number of sample story-narratives are included which hope to show that this form of writing can be utilised to revivify the personal archaeologies of everyday life