Nóra Kovács

Delivery of cardio-metabolic preventive services to Hungarian Roma of different socio-economic strata.

Background. Because the cardiovascular mortality in Hungary is high, particularly among the socio-economically deprived and the Roma, it is implied that primary health care (PHC) has a limited ability to exploit the opportunities of evidence-based preventions, and it may contribute to social health inequalities. Objectives. Our study investigated the underuse of PHC preventive services. Methods. Random samples of adults aged 21–64 years free of hypertension and diabetes mellitus were surveyed with participation rate of 97.7% in a cross-sectional study. Data from 2199 adults were collected on socio-demographic status, ethnicity, lifestyle and history of cardio-metabolic preventive service use. Delivery rates were calculated for those aged 21–44 years and those aged 45–64 years, and the influence of socio-demographic variables was determined using multivariate logistic regression. Results. Delivery rates varied between 12.79% and 99.06%, and the majority was far from 100%. Although most preventive service use was independent of education, younger participants with vocational educations underutilized problematic drinking (P = 0.011) and smoking (P = 0.027) assessments, and primary or less educated underutilized blood glucose (P = 0.001) and serum cholesterol (P = 0.005) checks. Health care measures of each lifestyle assessment (P nutrition = 0.032; P smoking = 0.021; P alcohol = 0.029) and waist circumference measurement (P = 0.047) were much less frequently used among older Roma. The blood glucose check (P = 0.001) and family history assessment (P = 0.043) were less utilized among Roma. Conclusions. The Hungarian PHC underutilizes the cardio-metabolic prevention contributing to the avoidable mortality, not generating considerably health inequalities by level of education, but contributing to the bad health status among the Roma.

Exploring quality of care and social inequalities related to type 2 diabetes in Hungary: Nationwide representative survey

AIMS The study aimed to launch a T2DM adult cohort that is representative of Hungary through a cross-sectional study, to produce the most important quality indicators for T2DM care, to describe social inequalities, and to estimate the absolute number of T2DM adult patients with uncontrolled HbA1c levels in Hungary. METHODS A representative sample of the Hungarian T2DM adults (N=1280) was selected in 2016. GPs collected data on socio-demographic status by questionnaire, and on history and laboratory parameters from medical records. The process and outcome indicators used in the international monitoring practice were calculated. The socio-economic status influence was determined by multivariate logistic regression models. RESULTS Target achievement was 61.66%, 53.48%, and 54.00% for HbA1c, LDL-C, and blood pressure, respectively, in the studied sample (N=1176). In Hungary, 294,534 patients have above target HbA1c value out of 495,801 T2DM adults. The education-dependent positive association with majority of process indicators was not reflected in HbA1c, LDL-C, and blood pressure target achievements. The risk of microvascular complications and requirement of insulin treatment were higher among less educated. CONCLUSIONS According to our observations, the education-independent target achievement for HbA1c and LDL-C is similar as, for blood pressure is less effective in Hungary than in Europe.

Special Health Care Utilization Pattern with Elevated Costs and High Risk of Premature Death Among Adults Living in Segregated Roma Settlements

Roma is the largest ethnic minority of Europe with poor health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health-indicators for adults living in segregated Roma settlements (SRS) representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR=1.152, 95%CI: 1.136–1.167). The proportion of subjects hospitalized (RR=1.286, 1.177–1.405), and the reimbursement for inpatient care (RR=1.060, 1.057–1.064) were elevated for SRS. Premature mortality was significantly higher in SRSs (RR=1.711, 1.085-2.696). Our study demonstrated that it is possible to compute the SRS-specific version of the routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue to a non-sensitive small area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of premature death.

Association between the General Practitioner Workforce Crisis and Premature Mortality in Hungary: Cross-Sectional Evaluation of Health Insurance Data from 2006 to 2014

The workforce crisis of primary care is reflected in the increasing number of general medical practices (GMP) with vacant general practitioner (GP) positions, and the GPs’ ageing. Our study aimed to describe the association between this crisis and premature mortality. Age-sex-standardized mortality for 18–64 years old adults was calculated for all Hungarian GMPs annually in the period from 2006 to 2014. The relationship of premature mortality with GPs’ age and vacant GP positions was evaluated by standardized linear regression controlled for list size, urbanization, geographical location, clients’ education, and type of the GMP. The clients’ education was the strongest protective factor (beta = −0175; p < 0.001), followed by urban residence (beta = −0.149; p < 0.001), and bigger list size (beta1601–2000 = −0.054; p < 0.001; beta2001−X = −0.096; p < 0.001). The geographical localization also significantly influenced the risk. Although GMPs with a GP aged older than 65 years (beta = 0; p = 0.995) did not affect the risk, GP vacancy was associated with higher risk (beta = 0.010; p = 0.033), although the corresponding number of attributable cases was 23.54 over 9 years. The vacant GP position is associated with a significant but hardly detectable increased risk of premature mortality without considerable public health importance. Nevertheless, employment of GPs aged more than 65 does not impose premature mortality risk elevation.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136–1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177–1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057–1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085–2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Influence of patient characteristics on preventive service delivery and general practitioners’ preventive performance indicators: A study in patients with hypertension or diabetes mellitus from Hungary

Abstract Background: Regular primary healthcare (PHC) performance monitoring to produce a set of performance indicators for provider effectiveness is a fundamental method for improving guideline adherence but there are potential negative impacts of the inadequate application of this approach. Since performance indicators can reflect patient characteristics and working environments, as well as PHC team contributions, inadequate monitoring practices can reduce their effectiveness in the prevention of cardiometabolic disorders. Objectives: To describe the influence of patients’ characteristics on performance indicators of PHC preventive practices in patients with hypertension or diabetes mellitus. Methods: This cross-sectional analysis was based on a network of 165 collaborating GPs. A random sample of 4320 adults was selected from GP’s patient lists. The response rate was 97.3% in this survey. Sociodemographic status, lifestyle, health attitudes and the use of recommended preventive PHC services were surveyed by questionnaire. The relationship between the use of preventive services and patient characteristics were analysed using hierarchical regression models in a subsample of 1659 survey participants with a known diagnosis of hypertension or diabetes mellitus. Results: Rates of PHC service utilization varied from 18.0% to 97.9%, and less than half (median: 44.4%; IQR: 30.8–62.5) of necessary services were used by patients. Patient attitude was as strong of an influencing factor as demographic properties but was remarkably weaker than patient socioeconomic status. Conclusion: These findings emphasize that PHC performance indicators have to be evaluated concerning patient characteristics.

Developing a database for Rett syndrome research performed in the European Union: A resource for researchers and stakeholders

BACKGROUND For most rare diseases, which are often significantly under-resourced, sufficient information on funding landscape is missing, which may prevent effective use of research resources and be an obstacle to making effective decisions on research. The objective of this research was to create a database of Rett syndrome research projects carried out in the European Union (EU) and to provide a research landscape analysis. METHOD Websites of organizations funding research projects were identified and systematically checked. Projects were analysed by date, place, funder types, and research topics. RESULTS The analysis revealed that the total expenditure on Rett syndrome research was almost €70 million, allocated among 247 projects mostly performed in Italy and the United Kingdom. The main research sponsor was the European Commission. Highlighting research trends and gaps, this work facilitates changes in rare disease research data management. CONCLUSION This work demonstrates the feasibility of creating an EU-based research database on Rett syndrome projects. It provides a source of information on research development which is useful for individuals, organizations and key players in the private and public sector to make progressive decisions on Rett syndrome research.

Smoking cessation support for regular smokers in Hungarian primary care: a nationwide representative cross-sectional study

Objectives Our study aimed to evaluate the effectiveness of general practitioners’ (GPs’) smoking cessation support (SCS). Study design We carried out a cross-sectional study between February and April 2016. Setting and participant A sample of 2904 regular smokers aged 18 years or older was selected randomly from 18 general medical practices involved in a national representative, general medical practice-based morbidity monitoring system. The GPs surveyed the selected adults and identified 708 regular smokers. Main outcome measures Multivariate logistic regression models have been applied to evaluate the determinants (age, gender, education, smoking-related comorbidity, smoking intensity, intention to quit smoking and nicotine dependence) of provision of GP-mediated SCS such as brief intervention, pharmacological and non-pharmacological programmatic support. Results According to the survey, 24.4% of the adults were regular smokers, 30% of them showed high nicotine dependence and 38.2% willing to quit smoking. Most of the smokers were not participated in SCS by GPs: brief intervention, programmatic non-pharmacological support and pharmacotherapy were provided for 25%, 7% and 2% of smokers, respectively. Low-nicotine-dependence individuals were less (OR 0.30, 95% CI 0.12 to 0.75), patients with intention to quit were more (OR 1.49, 95% CI 1.00 to 2.22) likely to receive a brief intervention. Vocational (OR 1.71, 95% CI 1.13 to 2.59) and high school education (OR 2.08, 95% CI 1.31 to 3.31), chronic obstructive pulmonary disease and cardiovascular diseases (OR 3.34, 95% CI 1.04 to 10.68; OR 3.91, 95% CI 2.33 to 6.54) increased the probability to receive support by GP. Conclusions Although there are differences among smokers’ subgroups, the SCS in Hungarian primary care is generally insufficient, compared with guidelines. Practically, the pharmacological support is not included in Hungarian GPs’ practice. GPs should increase substantially the working time devoted to SCS, and the organisation of primary healthcare should support GPs in improving SCS services.

Estimation of incidence, prevalence, and age-at-diagnosis of myasthenia gravis among adults by hospital discharge records

SummaryBackgroundThe Hungarian Health Insurance Fund, using appropriate information technology, covers all of the secondary care of the country and maintains a database of Hospital Discharge Records (HDR). Our study aimed to determine the incidence, average age-at-diagnosis (AaD), and prevalence of myasthenia gravis (MG) among adults and the regional heterogeneity of these measures to assess the potential usefulness of HDRs for monitoring.MethodsThe nationwide database of 336,679 HDRs from 2004 to 2009 was analyzed. The incidence and prevalence were determined for adults in 2007. Patients with MG code in 2007, 2008, and 2009 but without that in 2004–2006 were defined as incident. Distribution of AaD was described for these cases. Patients with an MG code in 2007, 2008, and 2009 were defined as prevalent in 2007. The heterogeneity of regional age-standardized indices was tested.ResultsThe observed incidence and prevalence was 2.76/100,000 (men: 2.37/100,000; women: 3.11/100,000) and 17.42/100,000 (male: 13.08/100,000; female: 21.28/100,000), respectively. These estimates were within published ranges. The mean AaD was significantly higher for men than for women (63.60 vs. 51.92; p < 0.001). Significant regional heterogeneity was observed for all measures.ConclusionsHDRs seem to be useful for developing MG indicators because they adequately estimate epidemiological parameters of MG occurrence.