Analyzing the evidence on European health care reforms

Health system reform, in Europe as elsewhere, has often been influenced as much by theory and conjecture as by fact and experience. In a study published in September 1997, the Regional Office for Europe of the World Health Organization (WHO) drew together the available evidence about the health care systems in the fifty-one countries of the European region. This paper focuses on western European countries. It reviews a variety of policy strategies and then explores implications from this European experience for the formulation of U.S. health care policy.     

The development of nursing: a European perspective

What do we mean by "Europe" and what is a European perspective? Those of us living in the European Union (EU) often equate Europe with our own "Western" countries, although as the EU itself expands even the term "Western" is increasingly inaccurate. The 50 Member States of the WHO European Region cover a huge area stretching from the western coast of Greenland to the Mediterranean, the Arctic and the Pacific coasts of the Russian Federation. "WHO Europe" is a loose geographical definition, since it incorporates all the republics of the former Soviet Union, including those in Central Asia.     

Surveillance of tuberculosis in Europe. Working Group of the World Health Organization (WHO) and the European Region of the International Union Against Tuberculosis and Lung Disease (IUATLD) for uniform reporting on tuberculosis cases

Consensus-based recommendations have been developed by a Working Group of the World Health Organization (WHO) and the European Region of the International Union Against Tuberculosis and Lung Disease (IUATLD) on uniform reporting of tuberculosis surveillance data in the countries of Europe. A uniform case definition and a minimum set of variables for reporting on each case have been agreed which, when collated on a national basis, will allow comparison of the epidemiology of tuberculosis in different European countries. The Working Group recommends that the case definition includes "definite" cases, where the diagnosis has been confirmed by culture (or supported by microscopy findings in countries where diagnostic culture facilities are not available), and "other than definite cases" based on a clinical diagnosis of tuberculosis combined with the intention to treat with a full course of antituberculosis therapy. Both "definite" and "other than definite" cases should be notified by physicians and, in addition, laboratories should be required to report "definite" cases. The minimum set of variables to be collected on each case of tuberculosis should include: date of starting treatment, place of residence, date of birth, gender, and country of origin, to characterize the patient. Recommended disease-specific variables include: site of disease, bacteriological status (microscopy and culture), and history of previous antituberculosis chemotherapy. The minimum set of variables should be collated on all patients and should be as complete as possible. Additional variables may be collected for individual, local or national purposes, but, in general, completeness of reporting on cases is likely to be better if the information requested is kept to a minimum. Timely reporting of cases is essential for appropriate public health action. Cases should be reported to the health authority at the local and/or regional level within 1 week of starting treatment. Individual-case based information should be reported to the national level by the local or regional level. Feedback to reporters is essential. At the national level, preliminary quarterly reports should be produced and final reports should be published annually.     

The 75 g oral glucose tolerance in pregnancy

The first case of the human immunodeficiency virus (HIV) infection was detected in Singapore in 1985 and the first case of the acquired immunodeficiency syndrome (AIDS) in 1986. Since then, the number of infections had increased. By the end of 1993, there were 222 residents with HIV infection, including 75 cases of AIDS. In view of the rapidly increasing magnitude of HIV infection, a microcomputer-based surveillance system was designed and developed in 1992 to better monitor epidemiological trends of HIV infection in Singapore. OBJECTIVE--The objective was to define a composite model of a successful HIV and AIDS registry that included: (a) patient data forms, (b) patient's contact data forms, (c) data analysis, and (d) report generation. METHODOLOGY--An IBM-compatible desk-top microcomputer was used for the project. The main software used for computer programming and data analysis were DBase IV (Version 1.5) and Epi Info (Version 5.0), respectively. Security features were incorporated into the programme to ensure confidentiality of information and that only authorized personnel could gain access to the programme. MAIN FINDINGS--The system functioned as the National HIV Notification Registry and was able to track notifications, analyse data and enabled prompt dissemination of information. The system was also linked to another database system for tuberculosis to enhance surveillance of both HIV infection and tuberculosis. CONCLUSION--The authors believe that this system would enhance surveillance and provide timely information for national AIDS control programmes. However, the effectiveness of this computer-based surveillance system is dependent on an established notification structure with notifications of sufficient completeness for both HIV infection and AIDS.     

Continuing medical education in Europe: a survey

The Continuing Medical Education (CME) in Europe Project is conducted by the World Federation for Medical Education, in conjunction with the Association for Medical Education in Europe, the Association for Medical Deans in Europe, and the European Office of the World Health Organization, with Upjohn Medical Sciences Liaison Division. The aim of the Project is to promote the development of CME in all European countries. It also has global relevance: all six Regions participated in initiating the Project, and its progress and outcomes will be generalized to the other five Regions. This Project coordinates information about the important developments in CME in all countries of Europe. In addition to this coordinating function, the Project has a dissemination function, promoting knowledge about good examples and CME experience (demonstration projects) in the countries of Europe. A survey was made of the methods of CME in each country, the informants being the members of the Project's CME Task Force. It consists of nominated representatives from the National Associations for Medical Education of countries in the European Region.     

Project plan for studies on suicide, attempted suicide, and suicide prevention

Completed and attempted suicide are major public health problems in most western countries. The importance of suicidal behavior as a health problem, particularly among adolescents and young adults, has been emphasized by the European Union, the WHO (Europe), as well as the Finnish authorities. Due to the exceptionally high suicide mortality, suicide prevention has been one of the main targets of Finnish health policy since the late 1980s. However, to develop feasible strategies for suicide prevention, better knowledge of the phenomenon of self-destruction is necessary. The Department of Mental Health of the National Public Health Institute has been actively involved in suicide research and the development of suicide strategies both in Finland and western Europe since 1986. The success is based on a long tradition of suicide research in Finland, the representative and reliable suicide data, a highly motivated research group, and also the necessary economic support by both the National Public Health Institute and the Finnish Academy. This article outlines our groups research plan for the next few years.     

Fluoridated etching on orthodontic bonding

To evaluate the impact of the 1993 expansion of the acquired immunodeficiency syndrome (AIDS) surveillance definition on reporting of persons with no HIV risk exposure information, we compared persons reported with and without risk in 1992 and 1993. The expanded case definition resulted in a large increase in both the number of persons reported with risk (121% increase) and without risk (167% increase). The changes in demographic characteristics for each group were similar from 1992 to 1993. Persons reported based on immunologic criteria were more likely and persons with pulmonary tuberculosis (PTB) less likely than those meeting the pre-1993 definition criteria to be reported with risk. Many persons with PTB were retrospectively identified from tuberculosis registries that do not systematically include HIV risk information. Ascertainment of risk information continues to be an essential part of AIDS surveillance with >90% of reports including risk exposure.     

Continuous improvement of oral health in Europe

The oral health action programmes of the WHO Regional Office for Europe (WHO/EURO) comply with the overall European Health Policy and targets for the improvement of health in Europe by the year 2000 (HFA2000) and focus on promotive and preventive care approaches primarily at the community level. Various activities, including the development of guidelines for local action projects, have been established to support WHO/EURO's Member States in initiating preventive oral health care system and introducing the concept of continuous quality development in oral health care. The main focus for Countries of Central and Eastern Europe (CCEE) is to formulate national goals for oral health and to further develop oral health services in the region. Collection of national data using agreed European quality indicators for oral health will form the basis of appropriate monitoring and development of technologies to improve oral health care services and the oral health status at large. The WHO/EURO action programmes aim to implement oral disease prevention and health promotion activities. Guidelines have been established to support individual Member States who intend to establish community-based programmes in accordance with scientifically sound principles and methods. The ORATEL Project (Telematic System for Quality Assurance in Oral Health Care) is part of the Commission of European Communities (CEC) strategy for harmonization and standardization in health care (CEC) Programme for advanced informatics in medicine--AIM/CEC) and ORATEL is the only AIM/CEC project related to oral health. The ORATEL Project aims to improve the oral health status in the European Region through use of appropriate computerized information systems. The Project will support management and administration of dental clinics and will be an integral part of a quality assurance system to promote a standardized level of quality in the field. Its advanced educational and decision-support tools can be used by professionals at all levels of the system. ORATEL possesses tools for aggregating and transmitting data upwards for monitoring and evaluation purposes at local, national and supranational administrative levels.     

No primary association between LMP2 polymorphisms and extraspinal manifestations in spondyloarthropathies

We present a case of multifocal tuberculosis of contralateral costo-transverse joints. Even in countries where tuberculosis is common, extrapulmonary multifocal infection is uncommon. Furthermore, a bilateral, symmetric distribution is distinctly unusual. The index of suspicion for tuberculosis should increase when the patient is from a country where tuberculosis is endemic or when a history of AIDS is present.     

The European Randomized Study of Screening for Prostate Cancer: an update

BACKGROUND: A consensus meeting on screening and global strategy for prostate carcinoma, held in Antwerp in 1994, determined the willingness among European cancer prevention centers to pursue vigorously the collaborative formation of a multinational randomized screening trial. This trial was to be named the European Randomized Study of Screening for Prostate Cancer (ERSPC). METHODS: During the years prior to that meeting, several feasibility trials were conducted in Antwerp and Rotterdam to evaluate the pitfalls and problems of a randomized procedure for population screening. Today, five centers in five European countries share their study work and results via the ERSPC, and others are lining up to join this massive effort. Regular meetings and specific work groups enable the research centers to compare their data, because the trial methodology differs slightly from one center to another. RESULTS: However, a common work strategy and analysis of the data has recently been reached, and the first study results of the trial (evaluating 180,000 men over a 10-year screening period) are expected by the year 2007. CONCLUSIONS: A randomized trial of prostate carcinoma screening is set up in Europe currently with five participating centers from five countries. First overall effect results of regular screening are expected after a 10-year period of follow-up.     

Self-perceived health in East and West Europe: another European health divide

There is a great, and possibly also a growing, difference in public health between the central, eastern (CEE) and western European countries. Several suggestions have been put forward as explanations for this health divide. A broader framework than one focusing on medical care systems or behavioural patterns is necessary to examine this difference. It will be more fruitful to try to identify social and economic factors at large, as well as specific explanatory factors. The aim of this study is to find out to what extent "The East-West Mortality Divide" was apparent in people's perception of their own health in 1990-1991, as a division in self-perceived health across Europe. If there were indeed differences, the aim is to examine whether or not they can be explained by specific economic and social conditions present in the early 1990s. Data from "World Values Survey 1990" reveal a striking east west divide in self-perceived health among people in the age group 35-64 yr, one of greater size than the gender gap in self-perceived health. The importance of a number of circumstances for people's self-perceived health in the 25 European countries was estimated. The assumption was that any resulting difference between eastern and western European countries could help to explain the health divide. An attempt was made to estimate how much the east-west health divide would be reduced if some of these circumstances were similar in CEE to those in the west. The results indicate that people's participation in civic activities has a positive effect on their health. This effect is recognised especially on a societal level. This supports theories about civic activities and community performance. In western Europe the tradition of the active citizen is more developed than in eastern Europe. People's life control was important for their self-perceived health in almost every European country, both in the west and the east. In the former communist countries, however, people did not feel that they had the same control over their lives as did people in the west. People's economic satisfaction was the most powerful predictor of self-perceived health, both in the eastern and western parts of Europe. The average level of economic satisfaction in 1990 1991 was considerably lower in CEE. If people's influence and economic resources were the same in the former communist countries as in the west, the health divide, according to my estimations, would decrease by something between 10-30%.     

Information in the ICU: are we being honest with our patients? The results of a European questionnaire

BACKGROUND: We were interested in determining the current practices and views of European intensive care doctors regarding communication with patients and informed consent for interventions. METHODS: A questionnaire was sent to the 1272 western European doctor members of the European Society of Intensive Care Medicine. All questionnaires were anonymous. Five hundred four completed questionnaires from 16 western European countries were analyzed. RESULTS: Of the respondents, 25 % said they would always give complete information to a patient, although 35 % felt they should. Thirty-two percent would give complete details of an iatrogenic incident, but 70% felt they should. There were significant differences in these attitudes between doctors from different countries, with doctors from the Netherlands more likely to give complete information, and doctors from Greece, Spain and Italy less likely. Fifty percent of the respondents required written consent for surgery, but for insertion of an arterial catheter oral consent was more widely accepted. The Netherlands and Scandinavia generally accepted oral requests for procedures, while Germany and the United Kingdom preferred written requests. Doctors of all countries were generally happy with their current practice concerning informed consent. Seventy-five percent would accept the right of a patient to refuse treatment, but 19% would carry out the procedure against the patient's wishes. CONCLUSIONS: Doctors are often not completely honest with their patients regarding their diagnosis or prognosis, or in the event of an iatrogenic incident. However, most doctors will respect a patient's right to refuse treatment. Informed consent practices vary substantially and are largely determined by locally accepted policy and accepted by doctors working in those areas.     

Hypertension and pulmonary edema associated with subconjunctival phenylephrine in a 2-month-old child during cataract extraction

We have analysed trends in male:female ratios among newborns between 1950 and 1990 in 29 countries from five continents. The numbers of liveborn males and females over the period 1950-1994 were derived from the World Health Organization (WHO) database. Countries for which reliable data were available included 20 major European countries (excluding the former Soviet Union, Albania and a few small countries), Canada, the USA, selected countries of Central and South America, Japan, Australia and New Zealand. From the original numbers of males and females, we computed the proportion of males among liveborns for each country and for selected broader areas within Europe. In most countries the proportion of male liveborns was constant during the study period. In particular, the proportion of male newborns in the European Union was 0.515 in 1950-1954, 0.514 in 1970-1974 and 0.514 in 1990-1994. In the USA, corresponding values were 0.513, 0.513 and 0.512. In Japan the ratios were 0.513 in 1950-1954, 0.516 and 1970-1974 and 0.514 in 1990-1994. Decreasing ratios were observed in some northern and eastern European countries plus Greece and Portugal and, particularly, in Mexico. In contrast, the proportion of male liveborns tended to increase in southern Europe and Australia. Overall, among the 29 countries considered, the proportion of males declined in 16, increased in six, and remained stable in seven.     

TBJ murine neuroblastoma resists dibutyryl cyclic AMP-induced differentiation and effects on metalloproteinase secretion

Bone mass in the Norwegian population appears to be the lowest in Europe. Depending on which skeletal part is measured, from 14 to 36% of Norwegian women over the age of 50 suffer from osteoporosis according to the WHO definition. In a European multicentre study of the prevalence of vertebral deformities (the EVOS study), prevalence was the third highest among men and women from Oslo. Incidence rates of forearm and hip fractures are higher in Norway than in other countries. There are, however, differences in hip fracture incidence within Norway itself, with the highest rates occurring in urban areas. Body height is greater and body mass index lower than in other European countries. Vitamin D receptor allele polymorphism was found to have no influence on bone mass in two studies.     

Mortality from tuberculosis in Spain from 1970 to 1993: changes in epidemiological trends during the acquired immune-deficiency syndrome epidemic

SETTING: Spain has the highest rates in Europe of the acquired immune-deficiency syndrome (AIDS), and probably a high rate of dual human immunodeficiency virus (HIV)/tuberculosis infection. OBJECTIVE: To determine the trends of tuberculosis mortality in Spain from 1970 to 1993, and to draw conclusions about the effects of the AIDS epidemic on these trends. DESIGN: Official population figures and data on deaths from tuberculosis were used to calculate specific tuberculosis mortality rates by age and sex (per 100000 population). Causes of death from tuberculosis were grouped according to the International Classification of Diseases. RESULTS: The crude death rate decreased from 10.28 to 1.84, with an annual mean decrease of 8.1% (95% confidence interval 7.5% to 8.7%). No changes in mortality from tuberculosis of the central nervous system (CNS) have been recorded since 1982, and none in mortality from other tuberculosis and in the age group 20-49 years since 1986. Mortality was higher among males and in the older age groups. The peak observed in the 1970s, due to the excess of deaths from CNS tuberculosis in children under the age of 5 years, has disappeared. CONCLUSION: Between 1970 and 1993, tuberculosis mortality in Spain decreased, although an excess of deaths occurred in young adults and from extra-pulmonary tuberculosis, coinciding with the AIDS epidemic.     

Geographic variation in mortality among individuals with youth-onset diabetes mellitus across the world. DERI Mortality Study Group. Diabetes Epidemiology Research International

The aim of this study was to evaluate the geographic variation in mortality among individuals with youth-onset insulin-dependent diabetes mellitus (IDDM) across the world. The study was based on the currently available IDDM incidence and mortality data. Mortality data for diabetes in the 0-24 year age group were obtained from the World Health Organization (WHO) statistics. The mortality rates were adjusted for the frequency of occurrence of IDDM and dividing the mortality rates by the IDDM incidence rates which were obtained from the WHO DiaMond project. There was a more than 10-fold geographic variation in mortality between the developed countries and Eastern European populations. The areas with the highest mortality rates were located in Japan, Eastern Europe and Russia. The areas having the best outcome associated with IDDM were Northern Europe, Central Europe, and Canada. An ecological study demonstrated a relationship between the incidence-adjusted mortality (estimated case-fatality) with IDDM incidence itself (Spearman's correlation coefficient = 0.45) as well as infant mortality and life expectancy at birth. These data demonstrated the possibility of an enormous geographic variation in mortality of youth-onset diabetic patients even in developed countries. It is important to note that these excess deaths are potentially preventable. The ecological study also suggested that the mortality differences may be in part related to overall and diabetes related care.     

Estimation of the infectious reservoir of Plasmodium falciparum in natural vector populations based on oocyst size

This paper summarizes a communication presented at the Second International Conference of Nuclear Cardiology, held in Cannes on 23-26 April 1995. The general evolution of nuclear medicine in Europe is examined within the context of European Union Directives, and the role of the Union of European Medical Specialists/Section of Nuclear Medicine is discussed. Thereafter consideration is given to the technical aspects of cardiovascular nuclear medicine procedures, and the situation with respect to such procedures in European countries is examined. In most European countries, nuclear medicine is a recognized specialty, while "nuclear cardiology" does not exist in its own right. In general, only nuclear medicine specialists have the responsibility for radionuclide studies, and most cardiovascular studies are performed under the direct responsibility of a licensed nuclear medicine specialist.     

Assessing obesity: classification and epidemiology

Obesity is generally defined as a body mass index (BMI) of 30 kg/m2 and higher. Overweight is defined as a BMI between 25 and 30 kg/m2. The prevalence varies considerably between countries, and between regions within countries. It is estimated that more than half of adults aged 35-65 living in Europe are either overweight or obese. Overweight is more common among men than among women but obesity is more common among women. The prevalence of obesity in Europe is probably in the order of 10-20% in men and 15-25% in adult women. In most European countries who have reliable data on time-trends the prevalence of obesity seems to be increasing. In most European countries, obesity is usually inversely associated with socio-economic status, particularly among women. New classifications of overweight may be based on cut-off points for simple anthropometric measures which reflects both total adiposity as well as abdominal fatness.     

The requisite internationalization of the campaign against smoking

One smoker out of two dies from smoking. Fifty five percent of the French population smoke at age 18. To decrease the tobacco consumption is thus a paramount public health objective. Following WHO and "Europe Against Cancer", a comprehensive program against smoking should ban advertising, increase prices, protect non-smokers, educate children, promote non-smoking behaviors and help smokers who want to stop. The measures taken in France, following the law of January 10th, 1991, made possible a 11.1% decrease of tobacco consumption and a 14.5% decrease of cigarette consumption. If France is exemplary for the ban of tobacco advertising, the means devoted to education and information are poor, the weakest in Europe. So, it is still possible to speed up the decrease of tobacco consumption in France so that the estimate of 165,000 deaths related to tobacco consumption in 2025 will not occur. This success has to be interpreted within a European and Worldwide context. The tobacco industry is responsible for denying the danger of tobacco, the addictive effect and nicotine and for targeting children and adolescents. Faced to the forecast of 100 million deaths within twenty years, only an international solution can be of the right size. WHO should be given this responsibility.     

A revised assessment of the HIV/AIDS incubation period, assuming a very short early period of high infectivity and using only San Francisco public health data on prevalence and incidence

A revised assessment of the HIV/AIDS incubation period has been made, based on an updated operational model that includes a very short early period of high infectivity, following recent work by Jacquez et al. and using AIDS incidence data from the San Francisco Department of Public Health, plus data on AIDS incidence and HIV prevalence in a specially recruited cohort from the San Francisco City Clinic. The incubation period has, approximately, a suitably scaled gamma distribution with 14 degrees of freedom and mean 12.8 (SE 0.2) years. This information is essential in interpreting data from other areas and regions where AIDS incidence figures only are available, and is in particular intended for applications to several countries in Europe.