Zdrav Var 2006; 45: 59-62 59 COMPLEMENTARY MEDICINE: EVIDENCE VERSUS EXPERIENCE? Edzard Ernst1 Complementary medicine (CM) has become important, not least because a large proportion of patients try it (often without telling their doctor), the media promote it, yet few people seem to understand it. In the following article I will try to highlight some of those aspects of CM which, I feel, are currently plagued by confusion, lack of transparency and sometimes even wilful deceit. Experience The long history of some forms of CM means that they have been “field-tested” in millions of patients. Surely this collective experience weighs heavy and, some insist, must outweigh the evidence from clinical trials which are usually only short-term, and comprise far less people. While this line of argument convinces many CM enthusiasts, it is wholly unconvincing to anyone capable of critical analysis. There are numerous reasons why experience can turn out to be a cumbersome method of reaching the wrong conclusions. There are also many examples where experience has misled our forefathers. Take blood letting, for instance: it was used for hundreds of years in all medical cultures for most medical conditions. Doctors were so impressed by its powers that, when trial data demonstrated its lack of effectiveness, they believed their experience and disbelieved the evidence. In CM, the supremacy of experience over evidence is still fairly obvious. We have shown, for instance, that authors of CM books seem to recommend almost any treatment for any condition (1): 120 CAM modalities for addiction, 131 for arthritis, 119 for asthma, 133 for cancer. But the climate is, I hope, slowly changing. More and more CM experts now recognize experience for what it is: a good method for formulating hypotheses but a very poor method for testing them. Evidence - negative or positive? It has always puzzled me how anyone could be for or against something like a medical intervention. Does it make sense to be for or against appendectomy or anticoagulants? I don’t think so! Why then do people hold emotional views on CM? In matters of healthcare, likes and dislikes should matter far less than evidence. Healthcare should not be a fashion where one might legitimately hold this or that opinion, nor must it be confused with religion in which one either believes or doesn’t. Medical treatments either demonstrably and reproducibly work or they don’t. Therefore reliable evidence on what is effective and safe must always be “good” - to view a trial of spiritual healing, homeopathy etc which fails to show that the tested intervention works (e.g. is better than placebo) as “negative” does simply not make sense. Examples include the recent (first ever) trial of shark cartilage for cancer (2). Its results showed that it has no beneficial effects. Surely this must be good news all around. Sharks will not die needlessly, cancer patients will not attach false hopes to a bogus treatment, money can be directed towards effective treatments. The only people who could possibly perceive this finding as “negative” are those involved in peddling bogus cancer cures and swindling desperate patients and their families of their savings. Neither researcher nor clinicians should be in the service of snake oil traders. Whenever we demonstrate that CM does work, the situation usually reverses. Examples for this scenario can also be found easily. Compelling evidence now suggests that real acupuncture is better than sham acupuncture for a range of pain-related syndromes, e.g. back pain (3). If the findings are based on good science, this must be good news: it could help millions who suffer from back pain, particularly as conventional medicine is not very successful in dealing with this problem. Many systematic reviews of rigorous clinical trials are available today demonstrating that certain CM approaches are efficacious for certain indications. Table 1 summarizes our endeavour to evaluate the existing trial data (1). It suggests that, for many CM methods, we now have compelling evidence that they are effective for specific conditions. Making more general use of these options could benefit many patients -provided that the risks of these remedies do not outweigh the benefit. Finding the evidence (arguably this is what science should be about) is always a good thing, particularly in medicine. As long as the results are reliable, they can only further our knowledge and will eventually improve healthcare. Sound evidence is always positive. University of Exeter & Plymouth, Department of Complementary Medicine, 25 Victoria Park Road, Exeter EX2 4NT, England Correspondence to: e-mail: Edzard.Ernst@pms.ac.uk 60 Zdrav Var 2006; 45 Table 1. List of conditions for which CM methods are effective. Condition Intervention AIDS/HIV (pallation) Stress management AIDS/HIV Exercise (symptomatic) Alzheimer's disease Ginkgo Anxiety Kava Anxiety Massage Anxiety Music Therapy Anxiety Relaxation Benign prostatic hyperplasia African plum Condition Intervention Benign prostatic hyperplasia Saw palmetto Cancer prevention Allium vegetables Cancer prevention Green tea Cancer prevention Tomato (lycopene) Cancer prevention Exercise Cancer prevention Aromatherapy/massage Cancer prevention Exercise Chronic fatigue syndrome Exercise Condition Intervention Chronic heart failure Hawthorn Chronic venous insufficiency Horse Chestnut Constipation Psyllium Depression Exercise Depression St. John's Wort Diabetes Guar gum Diabetes Psyllium Erectile dysfunction Yohimbine Condition Intervention Hypercholesterolemia Guar gum Hypercholesterolemia Oat Hypercholesterolemia Soy Hypertension Biofeedback Hypertension Co-enzyme Q10 Insomnia Relaxation Insomnia Melatonin Irritable bowel syndrome Fibre Condition Intervention Labor Pain Hypnosis Labor Pain Water immersion Menopause Red Clover Migraine Biofeedback Nausea and vomiting (induced by chemotherapy) Acupoint stimulation Nausea and vomiting (induced by chemotherapy) Relaxation Non-ulcer dyspepsia Peppermint and caraway Condition Intervention Osteoarthritis Acupuncture Osteoarthritis Phytodolor Osteoarthritis Chondroitin Osteoarthritis Glucosamine Osteoarthritis S-andenosylmethionine Overweight/obesity Ephedra sinica Peripheral arterial occlusive disease Ginkgo Peripheral arterial occlusive disease Padma 28 Condition Intervention Rheumatoid arthritis Diet Rheumatoid arthritis Phytodolor Smoking cessation Group behaviour therapy Upper respiratory tract infection Vitamin C (treatment not prevention) Legend This list is based on a review of the existing evidence. Only condition/intervention combinations are listed for which the amount, quality and quantity of evidence was sufficient and the direction of the evidence was clearly in favour of the intervention. Data extracted from reference 1. Ernst E. Complementary medicine: Evidence versus experience? 61 Poor Science In CM, many researchers seem to use science to prove that what they already believe is correct. Ye t science is not for proving but for testing. The former approach does not only reveal an unprofessional attitude, it is prone to seriously mislead us all. Emotions and strong beliefs can lead to bias (4), and bias leads to bad science. Sadly poor science is rife in CM. Here I could cite hundreds of examples. A recent study of anthroposophy (5) may suffice. Its aim was “to compare anthroposophic treatment to conventional treatment”. Patients elected to consult either an anthroposophic or a conventional doctor. The results of this study showed more favourable outcomes for the former approach. The authors concluded that “anthroposophic treatment… is safe and at least as effective as conventional treatment”. Because of numerous sources of bias and confounding, many other conclusions are just as likely (e.g. patients who elect to see an anthroposophic doctor differ in many ways from patients who consult a conventional physician). This example highlights much of what frequently is wrong with CM and CM research. It typifies how the aims of a study can be mismatched with the methodology and how the results may not justify the conclusions. If I had to name the characteristic that I find most disturbing in published CM research it would be this frequent inconsistency. Wishful thinking is, of course, only human. But the regularity of this incongruence in CM is nevertheless most remarkable. What follows is, I believe, more than obvious: poor science is bad - not because some ‘out-of-touch’ scientists in the ‘ivory towers’ think so - it is bad because it leads to wrong decisions in healthcare. Ultimately this will be detrimental to those who we should care for most: our patients. Double Standards In CM, double standards seem to be everywhere. They are typified, I fear, in the new and increasingly popular movement (its proponents would probably say ‘philosophy’) of ‘integrated medicine’! Its two basic tenets are that a) integrated medicine cares for the individual as a whole rather than looking at a diagnostic label and b) integrated medicine uses “the best of both worlds”(6). Both claims look superficially convincing and plausible; at closer inspection they are, however, neither. (7) Caring Table 2. Selected statements from a recent (government-sponsored) patient guide.* Statement (quote) ** Evidence *** .. the risk of a stroke (after upper spinal manipulation) is between 1 and 3 in 1 million manipulations. There are many published estimates that suggest much higher incidence figures. However, due to extreme under-reporting, the risk remains undefined. Acupuncture is being increasingly used for people trying to overcome addictions... A Cochrane review fails to demonstrate efficacy of acupuncture for this indication Craniosacral therapists treat a wide range of conditions from acute to chronic health problems... There is no trial evidence at all to suggest that craniosacral therapy is effective Healing is used for a wide range of... conditions. Research has shown benefit in many areas, including healing of wounds, ... migraine or irritable bowel syndrome..." The best evidence available to date fails to demonstrate effects beyond a placebo response "Homoeopathy is most often used to treat chronic conditions such as asthma" A Cochrane review fails to demonstrate efficacy of homoeopathy for asthma * Its aim was to “give (you) enough information to help you choose a complementary therapy that is right for you” ** The guide does not contain anything else by way of evidence on effectiveness (but was commissioned by the DoH to provide such evidence) *** Evidence extracted from reference 3 62 Zdrav Var 2006; 45 for the whole individual has always been and will always be a hallmark of any good medicine. (8) It is thus not legitimate to adopt it as a main characteristic that differentiates ‘integrated medicine’ from conventional healthcare - on the contrary, conventional healthcare professionals who work towards optimising patient care must feel insulted by it. Using “the best of both worlds” (i.e. CM and mainstream healthcare) sounds fine until one realises how crucially it hinges on the definition of “best”. In modern healthcare, this term can only describe those treatments that reproducibly do more good than harm. But this is precisely what evidence based medicine (EBM) is all about. Either ‘integrated medicine’ is synonymous with EBM (in which case the term would be redundant) or it applies a different standard for the term “best”. Considering what ‘integrative medicine’ in the UK currently promotes (Table 2), one has to conclude that the latter applies. This discloses integrative medicine as an elaborate smoke screen for adopting unproven treatments into routine healthcare (10). In the long run, this strategy can only turn out to be detrimental to everybody, including patients and even CM itself. Conclusion At present, CM seems to be in transition from an experience-based activity to an evidence-based area of healthcare. Only if CM applies the same standards as the rest of medicine does, will we be able to see its true value. And only then can we be sure that CM does more good than harm to those who count most: our patients. References 1. Ernst E, Pittler MH, Wider B, Boddy K. The desk top guide to complementary and alternative medicine. 2nd Edition. Edinburgh: Mosby/Elsevier. 2006. 2. Loprinzi CL, Levitt R, Barton DL, Sloan JA, Ahterton PJ, Smith DJ et al. Evaluation of shark cartilage in patients with advanced cancer. Cancer 2005; 104: 176-82. 3. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2004; 142: 651-63. 4. Ernst E.,Canter PH. Investigator bias and false positive findings in medical research. TRENDS in Pharmacological Sci 2003; 24: 219-21. 5. Hamre HJ, Fischer M, Heger M, Riley D, Haidvogl M, Baars E et al. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wien Klin Wochenschr 2005; 117: 256-68. 6. Rees L.,Weil A. Integrated medicine. BMJ 2001; 322: 119-20. 7. Ernst E. Disentangling integrative medicine. May Clin Proceed 2004; 79: 565-6. 8. Calman K. The profession of medicine. BMJ 1994; 309: 1140-3. 9. The Prince of Wales’s Foundation for Integrated Health: Complementary Healthcare: a guide for patients. 2005; www.fihealth.org.uk. 10. Smallwood C. The Role of Complementary and Alternative Medicine in the NHS. An investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. http://princeofwales.gov.uk/news/2005/ 10.oct/smallwood.php 2005. Zdrav Var 2006; 45: 63-66 63 KOMPLEMENTARNA MEDICINA: DOKAZI PROTI IZKU[NJAM? Edzard Ernst1 Uvodnik Komplementarna medicina (KM) se je uveljavila tudi zato, ker se k njej zateka veliko {tevilo bolnikov (mnogi od njih, ne da bi o tem obvestili svojega zdravnika) in ker jo priporo~ajo mno‘i~na ob~ila, ~eprav jo razumejo le redki. V ~lanku bom sku{al osvetliti predvsem tiste vidike KM, ki so po mojem mnenju zaradi zmede na tem podro~ju, nepreglednosti in celo namernega zavajanja, {e zlasti na udaru. Izku{nje Dolga zgodovina nekaterih oblik KM ka‘e, da so bile preizku{ene v praksi na milijonih bolnikov. Ta kolektivna izku{nja ima seveda precej{njo te‘o, po prepri~anju nekaterih mnogo ve~jo kot dokazi, pridobljeni s klini~nimi raziskavami. V te je zajetih precej manj ljudi in ponujajo le kratkoro~ne izsledke. Za mnoge zagovornike KM je to prepri~ljiv dokaz, ki pa ni sprejemljiv za vse, ki so sposobni kriti~ne presoje. [tevilni razlogi govore za to, da je sklepanje, ki temelji zgolj na osnovi izku{enj, lahko zmotno. To se je izkazalo `e ve~krat v preteklosti. Tak{en primer je pu{~anje krvi, ki so ga stoletja uporabljali v vseh kulturnih okoljih za zdravljenje ve~ine bolezni. Zdravniki so bili tako navdu{eni nad u~inki tega zdravljenja, da so raje verjeli svojim izku{njam kot dokazom tudi potem, ko so s poskusi dokazali njegovo neu~inkovitost. Na podro~ju KM izku{nje o~itno {e vedno nadvladajo dokaze. Pisci knjig o KM priporo~ajo skoraj vse na~ine zdravljenja za vse bolezni (1): 120 oblik KM za zasvojenost, 131 za artritis, 119 za astmo in 133 za raka. Kljub temu pa upam, da se bo stanje po~asi spremenilo. Vedno ve~ zdravilcev priznava, da so izku{nje koristne za postavljanje hipotez, a slabe za njihovo preverjanje. So izku{nje negativne ali pozitivne? Vedno sem se ~udil temu, da se nekdo lahko zavzema za nek medicinski poseg ali je proti posegu. Je smiselno, da nekdo zagovarja oz. nasprotuje odstranitvi slepi~a ali zdravilom proti strjevanju krvi? Mislim, da ne! Zakaj imajo potem ljudje ~ustven odnos do KM? Na podro~ju zdravstva mora imeti nagnjenje oziroma odpor do ne~esa mnogo manj{o te`o kot dokazi. Zdravstveno varstvo ni moda, kjer je dovoljen razli~en okus, pa tudi ne vera, kjer eni verujejo, drugi pa ne. Bistvo u~inkovitosti zdravljenja je dokazljivosti in ponovljivosti, zato so zanesljivi dokazi o tem, da je zdravljenje u~inkovito in varno, vedno lahko le “pozitivni. Ozna~iti raziskave duhovnega zdravljenja, homeopatije in drugih metod, za katere ni dokazov, da res delujejo (da so bolj u~inkovite kot placebo), kot “negativne,” je nesmisel. Eden tak{nih primerov je tudi nedavna {tudija o uporabi hrustanca morskega psa pri bolnikih z rakom (2), ki ni pokazala prav nobenih ugodnih u~inkov. To je za marsikoga zelo dobra novica: morski psi ne bodo po nepotrebnem umirali, bolniki z rakom se ne bodo ve~ z la`nim upanjem oprijemali tega zdravljenja in denar bo tako lahko namenjen drugim, u~inkovitim oblikam zdravljenja. Edini, ki te ugotovitve lahko sprejmejo kot negativne, so tisti, ki se ukvarjajo z la`nim zdravljenjem raka in ki obupane bolnike in njihove svojce goljufajo za njihove prihranke. Noben znanstvenik in noben zdravnik ne more zagovarjati prodajalcev ka~jega olja. Kadar koli doka`emo, da je KM u~inkovita, se stanje obi~ajno obrne. Tudi primerov za ta scenarij ni te`ko najti. Danes imamo prepri~ljive dokaze o tem, da je pri velikem {tevilu bole~inskih sindromov, npr. pri bole~inah v kri`u, prava akupunktura bolj u~inkovita od “akupunkture” (3).V primeru, da so do teh ugotovitev pri{li po znanstveni poti, je to prav gotovo dobra novica. Tako bi lahko pomagali milijonom ljudi z bole~inami v hrbtenici, {e zlasti zato, ker se uradna medicina v tem primeru ni izkazala kot zelo uspe{na. Izsledki sistemati~nih analiz klini~nih {tudij ka‘ejo, da so nekatere metode KM u~inkovite pri dolo~enih boleznih. Tabela 1 predstavlja povzetek na{ih prizadevanj, da bi ocenili podatke iz {tudij, ki so na voljo (1). Imamo prepri~ljive dokaze, da so mnoge oblike KM u~inkovite pri dolo~enih boleznih. S {ir{o uporabo teh na~inov zdravljenja bi lahko pomagali mnogim bolnikom pod pogojem, da tveganje ni ve~je od koristi, ki jih prina{ajo. Vedno si ‘elimo najti dokaze, {e zlasti na podro~ju medicine, saj je to bistvo znanosti. ^e so dokazi zanesljivi, lahko prispevajo k bolj{emu znanju in bolj kakovostnemu zdravljenju. Zanesljiv dokaz je namre~ vedno pozitiven. 1University of Exeter & Plymouth, Department of Complementary Medicine, 25 Victoria Park Road, Exeter EX2 4NT, England Kontaktni naslov: e-po{ta: Edzard.Ernst@pms.ac.uk 64 Zdrav Var 2006; 45 Tabela 1. Seznam bolezni, ki jih uspe{no zdravijo z KM. Bolezen Zdravljenje AIDS/HIV (paliativno ) obvladovanje stresa AIDS/HIV telesna dejavnost (simptomatsko) Alzheimerjeva bolezen ginkgo anksioznost kava anksioznost masaža anksioznost glasbena terapija benigna hiperlazija prostate afriška sliva benigna hiperplazija prostate Serenoa repans preprečevanje raka čebulnice preprečevanje raka zeleni čaj preprečevanje raka paradižnik (likopen) preprečevanje raka telesna dejavnost preprečevanje raka aromaterapija/masaža sindrom kronične utrujenosti telesna dejavnost kronična srčna odpoved glog kronična venska insuficienca divji kostanj zaprtje luske trpotca (Plantago ovata) depresija telesna dejavnost depresija šentjanževka sladkorna bolezen guar sladkorna bolezen luske trpotca( Plantago ovata) erektilna disfunkcija johimbin (alkaloid) hiperholesterolemija oves hiperholesterolemija soja zvišan krvni tlak biofeedback zvišan krvni tlak koencim Q10 nespečnost sproščanje nespečnost melatonin sindrom razdražljivega kolona vlaknine porodne bolečine hipnoza porodne bolečine porod v vodi menopavza rdeča detelja migrena biofeedback slabost in bruhanje (zaradi kemoterapije) akupunktura slabost in bruhanje (zaradi kemoterapije) sproščanje dispepsija brez ulkusa pepermint in kumina osteoartritis akupunktura osteoartritis Phytodolor osteoartritis glukozamin osteoartritis S-andenosilmetonin debelost efedra periferna okluzivna bolezen arterij gingko periferna okluzivna bolezen arterij Padma 28 revmatični artritis dieta revmatični artritis Phytodolor odvajanje od kajenja skupinska terapija Legenda Ta seznam temelji na pregledu razpolo`ljivih dokazov. Obsega le tiste bolezni in tiste vrste zdravljenja, pri katerih obstaja dovolj veliko {tevilo kakovostnih dokazov, ki govore v prid tem na~inom zdravljenja. Ernst E. Kompleterna medicina: dokazi proti izku{njam? 65 Slabo znanstveno delo Zdi se, da mnogi raziskovalci KM uporabljajo znanost le za dokazovanje pravilnosti ne~esa, o ~emer so `e prepri~ani, da je pravilno. Bistvo znanstvenega dela pa ni dokazovanje, temve~ testiranje. Ta pristop ne zrcali le neprofesionalnosti raziskovalcev, temve~ je tudi zavajajo~e. ^ustven odnos in vnaprej{nje prepri~anje lahko vodita v pristranost (4), posledica tega pa je slabo znanstveno delo. Na ‘alost, pa je tak{na znanost stalnica KM. S tem v zvezi bi lahko na{teli na stotine primerov, a dovolj je, ~e omenimo nedavno raziskavo o antropozofiji (5), v kateri so “primerjali antropozofsko in klasi~no zdravljenje”. Bolniki so se odlo~ali med antropozofskim in klasi~nim zdravnikom. Raziskava je pokazala ugodnej{e izide zdravljenja pri antropozofskem pristopu. Avtorji raziskave so pri{li do zaklju~ka, da je “antropozofsko zdravljenje varno in vsaj tako u~inkovito kot standardni na~in zdravljenja”. Zaradi {tevilnih dejavnikov, ki vodijo v zmoto in pristranost, so mo‘ni tudi druga~ni zaklju~ki. Tako se npr. tisti bolniki, ki se odlo~ijo za antropozofskega zdravnika, v mnogih pogledih razlikujejo od tistih, ki obi{~ejo klasi~nega zdravnika. Ta primer osvetljuje pogoste zmote KM in napake raziskav na tem podro~ju. Metodologija pogosto ni prilagojena ciljem in rezultati ne podpirajo vedno zaklju~kov. Pogostna zna~ilnost, ki me najbolj moti pri objavljenih raziskavah KM, je nedoslednost. V ~love{ki naravi je, da vidimo tisto, kar si `elimo videti, kljub temu pa je treba poudariti, da je neskladnost, ki jo redno sre~ujemo na podro~ju KM, prav velikanska. Menim, da je ve~ kot o~itno, da je pomanjkljiva znanost slaba, ne le zato, ker tako menijo znanstveniki v “slonoko{~enih stolpih”, oddaljeni od resni~nosti, temve~ zato, ker vodi do napa~nih odlo~itev na podro~ju zdravstva. Vse to pa gre na {kodo tistih, za katere bi morali najbolj poskrbeti - na {kodo na{ih bolnikov. Dvojna merila Zdi se, da so dvojna merila prisotna povsod na podro~ju KM. Bojim se, da so zna~ilna za novo in vedno bolj popularno gibanje (zagovorniki bi ga verjetno ozna~ili kot “filozofijo”) - integrirano medicino! Ta pa temelji na dveh bistvenih na~elih: a) ukvarja se s posameznikom kot s celoto in ne upo{teva le nalepke z diagnozo; b) uporablja “kar je najbolj{ega od obeh vrst zdravljenja” (6). Na prvi pogled se zdita zgornji trditvi verjetni in prepri~ljivi, ~e pa ju pogledamo pobli‘e nista ne eno ne drugo (7). Skrb za posameznika kot celoto in bo ostala za{~itni znak kakovostne medicine (8). Zato ni po{teno trditi, da je prav to zna~ilnost, po kateri se integrirana Tabela 2. Izjave, izbrane iz priro~nika za bolnike, ki je iz{el nedavno pod pokroviteljstvom vlade.* Izjava ** Dokaz *** ...tveganje za kap (po manipulaciji hrbtenice) je 1-3 na milijon manipulacij Objavljenih je bilo več ocen, ki navajajo precej večje številke. Zaradi pomanjkljivega poročanja pa tveganje ni opredeljeno. Akupunkturo vse več uporabljajo za premagovanje odvisnosti. Cochranovo poročilo ni dokazalo učinkovitosti akupunkture pri premagovanju odvisnosti. Strokovnjaki za kraniosakralno terapijo zdravijo najrazličnejše bolezni, od akutnih do kroničnih. Ni dokazov, ki bi potrjevali učinkovitost kraniosakralne terapije. Alternativno terapijo (healing) uporabljajo pri vrsti bolezni. Raziskave so pokazale njegove koristi na mnogih področjih, za celjenje ran, pri migreni in sindromu razdražljivega kolona. Homeopatijo pogosto uporabljajo za zdravljenje kroničnih bolezni, kot je npr. astma. Do danes še niso dokazali, da bi imelo to zdravljenje boljše učinke kot placebo. Cochrainovo poročilo ne navaja dokazov za učinkovitost homeopatije pri bolnikih z astmo. *Priro~nik za bolnike navaja, da je njegov cilj “navesti dovolj podatkov, ki bi bili v pomo~ pri izbiri ustreznega komplementarnega zdravljenja“ **Priro~nik ne vsebuje dokazil o u~inkovitosti terapij, ~eprav je Ministrstvo za zdravje naro~ilo, naj bodo vklju~eni ***Dokazi iz reference {t. 3. 66 Zdrav Var 2006; 45 medicina razlikuje od klasi~ne. Strokovnjaki s podro~ja uradne medicine, ki si prizadevajo za ~im vi{jo raven zdravstvenega varstva bolnikov, so lahko upravi~eno u‘aljeni. Trditev, da je najbolje uporabljati to, “kar je najbolj{e pri obeh vrstah zdravljenja “(pri KM in pri uradni medicini) zveni smiselno, dokler se ne zavemo, da je njeno bistvo definicija “najbolj{ega”. V modernem zdravstvu lahko s tem izrazom opi{emo le tiste vrste zdravljenja, za katere je dokazano, da ima od njih bolnik ve~ koristi kot {kode. In prav za to gre pri medicini, podprti z dokazi. Sta le dve mo‘nosti: ali pomeni “integrirana medicina” isto kot medicina, podprta z dokazi (v tem primeru je druga~no poimenovanje povsem odve~), ali pa zanjo veljajo druga~na merila za to, kaj je “najbolj{e”. ^e vidimo, kaj danes zagovarja integrirana medicina v Veliki Britaniji (9) (tabela 2), moramo ugotoviti, da velja zadnja trditev. Integrirana medicina je le dimna zavesa za uvajanje nepreverjenih na~inov zdravljenja v rutinske zdravstvene programe (10). Na dalj{i rok se lahko izka‘e, da je ta strategija pogubna za vse, tako za bolnike kot tudi za KM samo. Zaklju~ek Zdi se, da danes KM prehaja iz dejavnosti, temelje~e na izku{njah, v zdravstveno dejavnost, podprto za dokazi. Pravo vrednost KM bomo lahko spoznali le, ~e bo za~ela pri tem uporabljati enaka merila kot ostala podro~ja medicine. Le tako nas bo prepri~ala, da lahko ponudi bolnikom, ki so za nas najpomembnej{i, ve~ dobrega kot slabega. Literatura 1. Ernst E, Pittler MH, Wider B, Boddy K. The desk top guide to complementary and alternative medicine. 2nd Edition. Edinburgh: Mosby/Elsevier. 2006. 2. Loprinzi CL, Levitt R, Barton DL, Sloan JA, Ahterton PJ, Smith DJ et al. Evaluation of shark cartilage in patients with advanced cancer. Cancer 2005; 104: 176-82. 3. Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2004; 142: 651-63. 4. Ernst E.,Canter PH. Investigator bias and false positive findings in medical research. TRENDS in Pharmacological Sci 2003; 24: 219-21. 5. Hamre HJ, Fischer M, Heger M, Riley D, Haidvogl M, Baars E et al. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wien Klin Wochenschr 2005; 117: 256-68. 6. Rees L.,Weil A. Integrated medicine. BMJ 2001; 322:1 19-20. 7. Ernst E. Disentangling integrative medicine. May Clin Proceed 2004; 79: 565-6. 8. Calman K. The profession of medicine. BMJ 1994; 309: 1140-3. 9. The Prince of Wales’s Foundation for Integrated Health: Complementary Healthcare: a guide for patients. 2005; www.fihealth.org.uk. 10. Smallwood C. The Role of Complementary and Alternative Medicine in the NHS. An investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK. http://princeofwales.gov.uk/news/2005/ 10.oct/smallwood.php 2005. Zdrav Var 2005; 45: 67-80 67 SELECTED INDICATORS OF HEALTH CARE RESOURCES, AND HEALTH CARE UTILIZATION AND COSTS IN COUNTRIES OF THE “PUBLIC HEALTH IN SOUTH EASTERN EUROPE (PH-SEE)” NETWORK PRIMERJAVA IZBRANIH KAZALCEV ZMOGLJIVOSTI TER PORABE IN STRO[KOV ZDRAVSTVENEGA VARSTVA MED DR@AVAMI, SODELUJO^IMI V MRE@I “JAVNO ZDRAVJE V JUGOVZHODNI EVROPI (PH-SEE)” Doris Bardehle1, Ulrich Laaser2, Lijana Zaletel-Kragelj3 Prispelo: 3. 6. 2005 - Sprejeto: 25. 10. 2005 Original scientific article UDC 614(4-12) Abstract Background: The Public Health Collaboration in the South Eastern Europe (PH-SEE) network, including ten countries, was established under the aegis of the Stability Pact. Within the network a strong need was identified for monitoring several health and health care issues, including health care resources (HCR) and health care utilization and costs (HCUC). Aim/Purpose: To assess the current situation and trends in the PH-SEE countries in the field of HCR and HCUC during the period 1994 - 2003. Methods: The number of hospital beds, physicians, general practitioners, and dentists per 100,000 population, average length of hospital stay and total health expenditure as the percent of the gross domestic product were determined. A meta-database was established for the period 1994 - 2003. The ratios of indicator values of the PH-SEE countries to the EU average at the beginning and at the end of the observation period were calculated,as well as the differences between the initial and final values. Results: During the study period, the most notable change occurred in the ratios of the PH-SEE countries values to the EU average: i.e. in the hospital bed number in Moldova (beginning: 1.78, end: 0.96); in number of physicians in Moldova (beginning: 1.12, end: 0.76), in number of general practitioners in Moldova (beginning: 0.34, end: 0.56), in number of dentists in Moldova (beginning: 0.76, end: 0.50), in average length of hospital stay in Serbia&Montenegro (beginning: 1.07, end: 1.37), and in total health expenditure in Moldova (beginning: 0.73, end: 0.40). Conclusion: Considerable differences in HCR and HCUC were found between the PH-SEE countries. Some of these countries (e.g. Croatia, Greece and Slovenia) are in many respects close to the EU average, while the others (e.g. Albania) are faced with the problem of low economic power. The most stable PH-SEE country during the study period was Slovenia, while Moldova experienced the most rapid changes. Key words: public health, South Eastern Europe, health indicators, health care resources, health care utilization, health care costs Izvirni znanstveni ~lanek UDK 614(4-12) Izvle~ek Izhodi{~e: Pod okriljem Pakta za stabilnost je nastala mre‘a “Javno zdravje v Jugovzhodni Evropi (PH-SEE)”, v kateri sodeluje deset dr‘av. Med njimi se je pokazala potreba po stalnem sledenju pojavov, povezanih z zdravjem prebivalcev, med drugim tudi na podro~ju zmogljivosti ter porabe in stro{kov zdravstvenega varstva (ZV). 1Institute of Public Health North Rhine-Westphalia, Westerfeldstrasse 35-37, 33611 Bielefeld, Germany 2Faculty of Health Sciences, University of Bielefeld, POB 10 01 31 - D-33501 Bielefeld, Germany 3University of Ljubljana, Medical Faculty, Department of Public Health, Zalo{ka 4, 1000 Ljubljana Correspondence to: e-mail: lijana.kragelj@mf.uni-lj.si 68 Zdrav Var 2006; 45 Namen: Oceniti sedanje stanje in gibanje kazalcev na podro~ju zmogljivosti ter porabe in stro{kov ZV v dr‘avah PH-SEE v obdobju 1994-2003. Metode: Za oceno so bili izbrani naslednji kazalci: {tevilo bolni{ni~nih postelj, zdravnikov, zdravnikov splo{ne prakse in zobozdravnikov na 100.000 prebivalcev, povpre~no trajanje hospitalizacije ter odstotek bruto doma~ega proizvoda (BDP), ki se namenja za zdravje. Za obdobje 1994-2003 je bila vzpostavljena meta baza podatkov. Izra~unali smo razmerja med vrednostmi kazalcev v dr‘avah PH-SEE v primerjavi s povpre~jem EU na za~etku in na koncu opazovalnega obdobja ter razliko med njihovimi za~etnimi in kon~imi vrednostmi. Rezultati: Analiza je pokazala najve~je spremembe med za~etnimi in kon~imi vrednostmi razmerij med dr`avami PH -SEE mre`e in povpre~jem EU: v {tevilu bolni{ni~nih postelj v Moldaviji (za~etek: 1,78; konec: 0,96); v {tevilu zdravnikov v Moldaviji (za~etek: 1,12; konec: 0,76); v {tevilu splo{nih zdravnikov v Moldaviji (za~etek: 0,34; konec: 0,56); v {tevilu zobozdravnikov v Moldaviji (za~etek: 0,76; konec: 0,50), v povpre~nem trajanju hospitalizacije v Srbiji in ^rni gori (za~etek: 1,07; konec: 1,37) in v odstotku BDP za zdravje ponovno v Moldaviji (za~etek: 0,73; konec: 0,40). Zaklju~ki: Razlike v zmogljivosti ter porabe in stro{kov ZV so med dr‘avami mre‘e PH-SEE precej{nje. Nekatere od dr‘av (npr. Gr~ija, Hrva{ka in Slovenija) so v marsikaterem pogledu precej podobne povpre~ju EU, medtem ko se ostale dr‘ave (npr. Albanija) soo~ajo s problemi nizke ekonomske mo~i. V obdobju 1994-2003 so se vrednosti kazalcev najmanj spreminjale v Sloveniji, najbolj pa v Moldaviji. kazalniki zdravstvenega stanja, zmogljivost zdravstvenega Klju~ne besede: javno zdravje, Jugovzhodna Evropa, varstva, poraba in stro{ki zdravstvenega varstva 1 Introduction Health care systems in South Eastern Europe (SEE) are to a great extent influenced by transitional problems due to political and economic changes in the early nineties. They are predominantly oriented towards curative medicine, and public health services are inadequate. There is a lack of competence not only in health management and strategic development, but also in the fields of health surveillance and prevention. This situation calls for sustainable collaboration and transfer of knowledge and experience in the field of public health (PH). As a result, the Public Health Collaboration in South Eastern Europe, Programmes for Training and Research in Public Health – PH-SEE network was established within the Stability Pact for the SEE framework in 2000 (1), coordinated by the Andrija Stampar School of Public Health, University of Zagreb, Croatia, and the School of Public Health, University of Bielefeld, Germany. The countries participating in PH-SEE are : Albania, Bosnia&Herzegovina, Bulgaria, Croatia, Macedonia (Former Yugoslav Republic), Moldova, Romania, Serbia&Montenegro ( whenever possible the Kosovo territory is treated as a separate unit owing to special post-war circumstances), and Slovenia, while Greece is an associate partner. In 2001, the project called “Minimum Health Indicator Set” (MHIS PH-SEE) was endorsed as one of the prioritiy areas of the PH-SEE network (2). The set was developed and agreed on by all the participating countries in 2001/2002, and was piloted in 2003 (3). Its rationale was that health surveillance is a prerequisite for more optimal decision making in health policy, while valid indicators constitute the key to its meaningful analyses. As the usefulness of different indicators depends on the specific needs of a particular region, it is essential to establish a specific indicator set. The MHIS PH-SEE is based on health targets of the WHO “Health21” strategy (HEALTH21) (4), and covers its main categories. It was agreed to base the MHIS upon the health indicator list of WHO, Regional Office for Europe (WHO-EURO) (5) and on the Final Report of the “European Community Health Indicators’” project of the European Commission (6, 7). The study of these indicators was undertaken to assess the current situation and trends in the field of health care resources (HCR) and health care utilization and costs (HCUC) in the PH-SEE countries for the period 1994 - 2003. 2 Material and methods 2.1 The meta-database The meta-database was constructed and completed using several sources: a) the WHO-EURO Health for All database (WHO-HFADB), the version available at the time of piloting (8), which was revised in 2005 (issued in June 2005) (9); b) information provided by the European Observatory on Health Care Systems (10-18), and c) for Kosovo, data published in the European Journal of Public Health (19). Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 69 2.2 Indicators Indicators of health care resources. According to the feasibility study (3) criteria for inclusion in the MHIS PH-SEE database for monitoring health care services were met by the indicator “hospital beds per 100,000 population”. Three indicators met the standards for monitoring human resources: “physicians per 100,000 population”, “general practitioners (GPs) per 100,000 population”, and “dentists per 100,000 population”. All indicators are defined according to the definition adopted for WHO-EURO Health for all Database (5). Health care utilization and costs. Inclusion standards for monitoring HCUC were met by two indicators: “average length of hospital stay, all hospitals”, and “total health expenditure as a percent of gross domestic product (GDP)”. For the purpose of the present study a general indicator of economic situation, GDP in US$ per capita, was added. The definitions adopted for WHO-EURO Health for all Database (5) were used for the standards. 2.3 Methods Time frame. The data for the 10-year period 1994-2003 were analysed. Benchmarking. For the benchmarking of the data of PH-SEE countries, the European Union (EU) average was agreed on (2,3). For the purpose of this study the EU-15 (EU before May 2004) average was agreed on. Methods of analysis. All MHIS PH-SEE indicators were analysed using descriptive statistical and qualitative methods, as follows: – the differences between the PH-SEE country with the highest and the PH-SEE country with the lowest indicator values were computed for the years 1994 and 2002 (for 2003 the reporting of indicators to WHO-HFADB was not finished in all PH-SEE countries, and the EU-15 average was not yet known this year was therefore inappropriate for making comparisons); – the global trend for each of the indicators in each PH-SEE country for the period 1994 - 2003 was assessed using the qualitative method of subjective classification of trends in the following groups: constantly decreasing if not even a slight increase was traced, globally decreasing if only a slight increase was recorded only once, globally increasing if only a slight increase was documented only once, constantly increasing if even not a slight decrease was traced, or oscilating if the values were changeable in trend. – the ratios of indicator values in the PH-SEE countries to the EU-15 values for 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year period were computed; the year 2002 was selected because data on indicators for 2003 were not available in several countries; – global change in each country was assessed by the following procedure: a) for each indicator the coutries were ranked by the difference in ratios between 1994 and 2002; b) for each country the mean rank of ranks in difference in ratios between 1994 and 2002 was calculated; c) the countries were ranked by the mean rank. Statistical tools. Statistical analyses were performed using the SPSS statistical package for Windows (Version 11.0, SPSS Inc., Chicago IL, USA). 3 Results 3.1 Health care resources Hospital beds per 100,000 population. The values for 1994 ranged from 302 in Albania to 1,222 in Moldova (the value for Bosnia&Herzegovina was not reported) (range of difference: 920),and in 2002, from 310 in Bosnia&Herzegovina to 746 in Romania (the values for Greece and Macedonia were missing) (range of difference: 436) (Table 1). During the period 1994 -2003, a constant decrease in this indicator value was globally registered in EU. Similar situation was observed in Greece, Macedonia and Slovenia. In Bulgaria a steady decrease of values started in 1996. In all other countries an oscillation in values, or an upward trend were observed. For Kosovo no data were available. The ratios of PH-SEE countries value to the EU-15 average in 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year period, are shown in Table 2. The greatest change in ratio (-0.82) occurred in Moldova. Physicians per 100,000 population. In 1994 the values ranged from 132 in Albania to 384 in Greece (for Bosnia&Herzegovina the value was not available) (range of difference: 224), and in 2002 from 133 in Albania to 352 in Bulgaria (data for Greece and Macedona were not reported) (range of difference: 219) (Table 1). During the period 1994 - 2003 a constant increase in this indicator was globally recorded in EU. In Bulgaria, Croatia, Romania and Serbia&Montenegro an increasing trend was noted; in Albania, Bosnia&Herzegovina and Slovenia the values oscillated around a similar value, while in Moldova a considerable decrease occurred during the period 1999 -2002. For Kosovo no data were available. The ratios of PH-SEE countries’ values to the EU-15 average in 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year 70 Zdrav Var 2006; 45 period, are shown in Table 2. The greatest change in ratio (-0.36) was recorded in Moldova. General practitioners per 100,000 population. In 1994 the figures ranged from 35 in Moldova, to 99 in Macedonia (data for Bosnia & Herzegovina, Greece and Serbia&Montenegro were not reported) (range of difference: 64), and in 2002 from 23 in Bosnia&Herzegovina to 68 in Croatia (but data for Greece, Macedonia and Romania were not reported) (range of difference: 45) (Table 1). During the period 1994 - 2003 more or less stable values of this indicator were globally registered in EU. In Bulgaria, Croatia, Romania and Serbia&Montenegro an unpward trend was observed, in Albania, Bosnia&Herzegovina and Slovenia, the values oscillated around the similar value, while in Moldova a considerable decrease occurred during the period 1999 - 2002. No data, however, were available for Kosovo. The ratios of PH-SEE countries values to EU-15 average in 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year period are indicated in Table 2. The greatest change in ratio (+0.22) was recorded in Moldova (but the differences for Greece and Serbia&Montenegro were not assessed because data were missing). Dentists per 100,000 population. In 1994 the values ranged from 26 in Romania to 103 in Greece (data for Bosnia&Herzegovina were not available) (range of difference: 77), and in 2002 from 18 in Bosnia & Herzegovina to 78 in Bulgaria (data for Greece and Macedonia were not available ) (range of difference: 60) (Table 1). In the period 1994 -2003 more or less stable values of this indicator were globally reported in EU. In Bulgaria, Croatia, Romania and Serbia & Montenegro an increasing trend was noted, in Albania, Bosnia&Herzegovina and Slovenia the values oscillated around the similar value, while in Moldova a considerable decrease occurred during the period 1999 -2002. No data were available for Kosovo. The ratios of PH-SEE countries values to the EU-15 average in 1994 (or the nearest year available) and in 2002 (or the nearest year available), and the differences in ratios in the 9-year period, are indicated in Table 2. The greatest change in ratio (-0.26) was observed in Moldova. 3.2 Health care utilization and costs Average length of hospital stay, all hospitals. The values for 1994 ranged from 9.0 in Albania and Greece to 17.3 in Moldova (data for Bosnia&Herzegovina were not available) (range of difference: 8.3), and for 2002 from 6.8 in Albania to 12.1 in Serbia&Montenegro (data for Greece and Macedonia were not reported) (range of difference: 5.3) (Table 3). During the period 1994 - 2003 a constant decrease in values of this indicator was globally reported in EU. Similar process was observed in Albania, Bosnia&Herzegovina, Bulgaria, Croatia, Greece and Slovenia. In Macedonia, Moldova and Romania there was first an increase and then a decrease, while in Serbia&Montenegro the initial decrease was followed by an increase. Data for Kosovo were not available. The ratios of PH-SEE countries values to the EU-15 average in 1994 (or the nearest year available) and in 2002 (or the nearest year available), and the differences in ratios in the 9-year period, are shown in Table 4. The greatest change in ratio (+0.30) occurred in Serbia&Montenegro. Total health expenditure as a per cent of gross domestic product (GDP). In 1994 the figures ranged from 2.8 for Albania to 9.7 for Greece (information for Bosnia&Herzegovina and Macedonia was not provided) (range of difference: 6.9), and in 2002 from 2.2 in Albania to 9.5 in Greece (data for Bosnia&Herzegovina, Bulgaria, Croatia, Macedonia, Serbia&Montenegro and Slovenia were not reported) (range of difference: 7.3) (Table 3). Between 1994 and 2003, a slight increase in the values of this indicator was globally reported in EU. In all PH-SEE countries major or minor oscillations were noted (in Bosnia&Herzegovina, Bulgaria, Croatia and Macedonia trends were not estimated because of the lack of data). For Kosovo the estimated value for 2000 was 2.5. The ratios of PH-SEE countries values to the EU-15 average in 1994 (or the nearest year available) and in 2002 (or the nearest year available), and the differences in ratios in the 9-year period, are demonstrated in Table 4. The estimated ratio for Kosovo was 0.27. The greatest change in ratio (-0.33) occurred in Moldova. Gross domestic product, US$ per capita. In 1994 the values ranged from 327 in Moldova to 9632 in Greece (values for Albania, Bosnia&Herzegovinia, Bulgaria, Romania and Serbia&Montenegria were not reported) (range of difference: 9305), and in 2002 from 382 in Moldova to 12494 in Greece (but data for Serbia&Montenegro were not reported available) (range of difference: 12112) (Table 3). Between 1994 and 2003 more or less stable values of this indicator were globally noted in EU. Generally, an increase occurred in most PH-SEE countries (in Albania, Bosnia&Herzegovina, Bulgaria, and Romania the estimation of trends was impeded by the missing data, and in Serbia&Montenegro estimation was impossible because of lack of data). For Kosovo no data were available. The ratios of PH-SEE countries values to the EU-15 average in 1994 (or the nearest year available) and in 2002 (or the nearest year available), and the differences in ratios in the 9-year period, are indicated in Table 4. The greatest change in ratio (+0.13) occurred in Slovenia. Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 71 Table 1. Selected indicators on health care resources for countries collaborating in the field of public health in South Eastern Europe (PH-SEE), 1994-2003, compared to the European Union average. Tabela 1. Izbrani kazalci virov zdravstvene oskrbe v dr`avah, ki sodelujejo v mre`i “Javno zdravje v Jugovzhodni Evropi (PH-SEE)” za obdobje 1994-2003, primerjava s povprecjem EU (EU before May 2004). Year/Leto Country/Drzava 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Hospital beds per 100,000 population Število bolniških postelj na 100.000 prebivalcev Albania 319 314 305 305 303 326 326 314 307 Bosnia&Herzegovina 382 380 324 322 310 314 Bulgaria 1020 1037 1047 1028 841 749 741 720 649 629 Croatia 591 575 619 601 606 593 615 600 567 561 Greece 491 491 491 487 485 472 472 Macedonia (FYR*) 555 542 520 516 515 510 506 494 Moldova 1222 1221 1213 1162 1123 819 759 589 577 667 Romania 769 764 756 738 731 731 744 749 746 656 Serbia&Montenegro 543 531 551 553 548 541 599 Slovenia 578 575 566 567 562 555 543 516 508 496 EU before May 2004 687 672 663 647 637 626 615 608 600 Physicians per 100,000 population Število zdravnikov na 100.000 prebivalcev Albania 131 130 129 129 128 139 134 133 Bosnia&Herzegovina 143 144 142 145 144 146 Bulgaria 333 346 354 345 345 344 337 344 352 360 Croatia 201 204 225 226 229 229 238 238 238 244 Greece 384 386 388 399 413 424 433 438 Macedonia (FYR*) 232 230 225 225 225 221 220 219 Moldova 356 351 356 358 363 325 318 271 270 311 Romania 176 177 181 179 184 191 189 189 191 196 Serbia&Montenegro 199 202 205 212 214 213 268 Slovenia 219 212 213 215 218 215 218 219 224 EU before May 2004 319 322 329 334 337 343 350 353 356 General practitioners per 100,000 population Število splošnih zdravnikov na 100.000 prebivalcev Albania 54 60 49 46 46 50 51 50 Bosnia&Herzegovina 29 25 25 23 23 21 Bulgaria 76 80 80 67 65 67 68 Croatia 76 73 68 68 71 69 68 68 Greece Macedonia (FYR*) 99 100 93 93 92 92 91 85 Moldova 35 33 34 35 40 53 59 54 Romania 75 74 74 81 44t Serbia&Montenegro 55 Slovenia 37 44 41 39 47 45 46 46 47 EU before May 2004 102 105 103 103 102 102 102 102 102 Dentists per 100,000 populatior Število zobozdravnikov na 1Ö0.Ö00 prebivalcev Albania 35 31 41 41 Bosnia&Herzegovina 19 20 19 18 18 18 Bulgaria 66 65 66 63 59 57 83 82 78 83 Croatia 54 56 62 62 66 64 68 68 68 69 Greece 103 100 107 108 110 112 113 113 Macedonia (FYR*) 56 55 54 55 57 56 56 55 Moldova 44 44 43 43 43 42 37 31 33 39 Romania 26 27 26 24 24 23 22 23 22 23 Serbia&Montenegro 39 39 39 40 39 39 47 Slovenia 53 64 57 59 61 60 59 59 60 EU before May 2004 58 59 60 61 62 63 64 65 66 Sources: WHO Health for All database (9), European Observatory on Health Care Systems (10-18) Legend: * - Former Yougoslav Republic; † - European Observatory on Health Care Systems data (10-18) Viri: SZO podatkovna baza “Health for All” (9), European Observatory on Health Systems (10-18) Legenda: *- biv{a jugoslovanska republika; European Observatory on Health Care Systems (10-18) 72 Zdrav Var 2006; 45 Table 2. The ratios of indicators values on health care resources of the Minimum Health Indicator Set of countries collaborating in the field of public health in the South Eastern Europe (PH-SEE) to the values of European Union average (EU-15 average = EU average before May 2004) in 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year period. Tabela 2. Razmerje med vrednostmi kazalcev o virih zdravstvene oskrbe v dr‘avah, ki sodelujejo v mre‘i “Javno zdravje v Jugovzhodni Evropi (PH-SEE)”, in med povpre~no vrednostjo v EU (EU-15 average = povpre~je EU pred majem 2004) l.1994 (ali v najbli‘jem letu, ki je na voljo) in l.2002 (ali v najbli‘jem letu, ki je na voljo), in razlike med temi razmerji v obdobju 9 let. PH-SEE Network country Države elanice mreže PH-SEE Year*/ Leto* EU-15 average ra 'E n < IO C ođ O n oi O 0) mi I ! I n Ë I ra 'E n E o O) (0 O) «si 1994 2002 Difference/Razlika 1994 2002 Difference/Razlika 1994 2002 Difference/Razlika 1994 2002 Difference/Razlika I Hospital beds per 100,000 population Število bolniških postelj na 100.000 prebivalcev 0.44 0.56 1.48 0.86 0.71 0.81 1.78 1.12 0.79 0.84 0.52 0.52 1.08 0.95 0.79 0.82 0.96 1.24 1.00 0.85 0.08 -0.04 -0.40 0.09 0.08 0.01 -0.82 0.12 0.21 0.01 Physicians per 100,000 population Število zdravnikov na 100.000 prebivalcev 0.41 0.45 1.04 0.63 1.20 0.73 1.12 0.55 0.62 0.69 0.37 0.40 0.99 0.67 1.23 0.61 0.76 0.53 0.75 0.63 -0.04 -0.05 -0.05 0.04 0.03 -0.12 -0.36 -0.02 0.13 -0.06 General practitioners per 100,000 population Število splošnih zdravnikov na 100.000 prebivalcev 0.53 0.29 0.75 0.74 0.97 0.34 0.73 0.36 0.49 0.23 0.66 0.67 0.83 0.56 0.79 0.54 0.46 -0.04 -0.06 -0.09 -0.07 -0.14 0.22 0.06 0.10 Dentists per 100,000 population Število zobozdravnikov na 100.000 prebivalcev 0.69 0.33 1.13 0.93 1.77 0.96 0.76 0.45 0.67 0.91 0.63 0.28 1.19 1.04 1.72 0.84 0.50 0.34 0.71 0.92 -0.06 -0.05 0.06 0.11 -0.05 -0.12 -0.26 -0.11 0.04 0.01 Legend: * - the stated year or the nearest year available; † - Former Yougoslav Republic Legenda: * - ozna~eno leto ali najbli‘je razpolo‘ljivo leto; biv{a jugoslovanska republika Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 73 Table 3. Selected indicators on health care utilization and costs for countries collaborating in the field of public health in South Eastern Europe (PH-SEE), 1994-2003, compared to the European Union average. Tabela 3. Izbrani kazalci uporabe in stro{kov zdravstvenega varstva v dr‘avah, ki sodelujejo v mre‘i “Javno zdravje v Jugovzhodni Evropi (PH-SEE)” za obdobje 1994-2003, primerjava s povpre~jem EU (EU before May 2004). Year/Leto Country/Drzava 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Average length of stay, all hospitals Povpreeno trajanje hospitalizacije, vse bolnišnice Albania 8.2 8.1 7.9 7.6 7.5 6.9 6.7 6.8 6.6 Bosnia&Herzegovina 11.5 11.0 11.1 10.5 10.7 10.3 Bulgaria 13.6 13.6 13.2 12.9 12.5 11.9 11.5 10.7 9.2 8.8 Croatia 13.8 13.2 13.4 12.9 12.6 12.3 11.9 11.8 11.2 11.0 Greece 9.0 8.5 8.6 8.7 8.3 Macedonia (FYR*) 14.0 14.3 14.0 13.4 12.7 12.6 12.2 11.8 Moldova 17.3 17.5 18.1 18.0 17.6 16.3 14.2 12.5 11.5 10.8 Romania 10.3 11.0 10.0 10.0 10.0 9.5 8.9 8.7 8.2 8.0 Serbia&Montenegro 13.0 12.0 12.0 12.0 12.0 11.0 12.1 Slovenia 10.6 10.4 10.5 10.0 9.5 9.0 8.6 8.3 8.1 7.4 EU before May 2004 12.1 11.5 11.3 10.9 10.5 9.9 9.6 9.2 8.8 8.7 Total health expenditure as % of gross domestic product (GDP) Vsi stroški zdravstvenega varstva kot % BDP Albania 2.8 2.4 2.2 2.1 1.9 2.3 2.0 2.1 2.2 2.3 Bosnia&Herzegovina 7.2t 7.7t Bulgaria 4.7 3.2t 3.5t 3.4t Croatia 9.0 7.3t 7.2t Greece 9.7 9.6 9.4 9.6 9.7 Macedonia (FYR*) 5.6 4.5 Moldova 6.2 5.8 6.9 6.0 4.3 2.9 3.0 2.9 3.6 4.0 Romania 3.0 3.2 3.4 3.1 4.1 3.9 4.1 4.1 4.2 4.1 Serbia&Montenegro 9.5 8.7 8.0 9.1 7.6 6.9 7.6 Slovenia 7.9 7.8 7.8 7.7 7.8 7.7 8.0 8.2 EU before May 2004 8.5 8.6 8.7 8.6 8.6 8.6 8.7 8.9 9.1 Gross domestic product, US$ per capita BDP, US$ na prebivalca Albania 906 1,300 1,535 Bosnia&Herzegovina 1,175 1,362 Bulgaria 1,474 1,690 1,944 Croatia 3,139 4,029 4,422 4,362 4,663 4,777 4,625 5,025 Greece 9,632 11,244 11,811 11,577 11,561 11,902 11,063 12,494 Macedonia (FYR*) 1,616 1,583 1,581 1,593 1,860 Moldova 327 392 442 255 346 382 Romania 1,545 1,503 1,728 2,052 Serbia&Montenegro Slovenia 7,233 9,431 9,481 9,163 9,847 10,450 1,1181 EU before May 2004 20,310 23,275 23,593 22,124 22,868 22,795 20,908 20,863 2,2745 Sources: WHO Health for All database (9), European Observatory on Health Care Systems (10-18) Legend: * - Former Yougoslav Republic; † - European Observatory on Health Care Systems data (10-18) Viri: SZO podatkovna baza “Health for All” (9), European Observatory on Health Systems (10-18) Legenda: *- biv{a jugoslovanska republika; European Observatory on Health Care Systems (10-18) 74 Zdrav Var 2006; 45 Table 4. The ratios of values of indicators on health care utilization and costs of the Minimum Health Indicator Set of countries collaborating in the field of public health in the South Eastern Europe (PH-SEE) to the values of European Union average (EU-15 average = EU average before May 2004) in 1994 (or the nearest year available) and 2002 (or the nearest year available), and the differences in ratios in the 9-year period. Tabela 4. Razmerje med vrednostmi kazalcev uporabe in stro{kov zdravstvene oskrbe v dr‘avah, ki sodelujejo v mre‘i “Javno zdravje v Jugovzhodni Evropi (PH-SEE)”, in med povpre~no vrednostjo v EU (povpre~je EU-15 = povpre~je EU pred majem 2004) v 1994 (ali v najbli‘jem letu, ki je na voljo) in v 2002 (ali v najbli‘jem razpolo‘jivem letu) in razlike med temi razmerji v obdobju 9 let. PH-SEE Network country Year*/ Leto* EU-15 average (0 n 08 o (0 O) ë V » ü O 0) m z I 1 0) u 0) m Ë n > o TJ ra E o O) ra a) q> o (O S n c 0) > o (0 1994 2002 Difference/Razlika 1994 2002 Difference/Razlika 1994 2002 Difference/Razlika 0.74 0.77 0.03 Total 0.33 0.24 -0.09 0.04 0.07 0.03 Avgerage length of stay, all hospitals Povpreeno trajanje hospitalizacije, vse bolnišnice 0.95 1.12 1.14 0.74 1.15 1.43 0.85 1.07 1.21 1.04 1.27 0.94 1.34 1.31 0.93 1.37 0.26 -0.08 0.13 0.20 0.19 -0.12 0.08 0.30 health expenditure as % of gross domestic product (GDP) Vsi stroški zdravstvenega varstva kot % BDP 0.85 0.85 0.00 0.06 0.06 0.00 0.56 1.06 1.14 0.66 0.73 0.38 0.80 1.05 0.50 0.40 -0.18 -0.26 -0.09 -0.16 -0.33 Gross domestic produotJS$ per capita BDP, US$ na prebivalca 0.07 0.15 0.47 0.08 0.02 0.09 0.22 0.55 0.08 0.02 0.02 0.07 0.08 0.00 0.00 0.35 0.46 0.11 0.08 0.09 0.01 1.12 0.84 -0.28 0.87 0.92 0.05 0.93 0.91 -0.02 0.36 0.49 0.13 Legend: * - the stated year or the nearest year available; † - Former Yougoslav Republic Legenda: * - ozna~eno leto ali najbli‘je razpolo‘ljivo leto; biv{a jugoslovanska republika Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 75 3.3 Profiles of the PH-SEE network countries in the field of HCR and HCUC According to the data available for the period 1994 -2003 the greatest changes were reported in Moldova, where during the 9-year period the ratio of hospital beds per 100,000 population to EU decreased globally from 1.78 to 0.96 and the ratio of physicians per 100,000 population from 1.12 to 0.36; for GPs per 100,000 poplation it increased from 0.34 to 0.56, and for dentists per 100,000 population it decreased from 0.76 to 0.50. Furthermore, the greatest decrease in total health expenditure as a percent of GDP was reported in this country (from 0.73 to 0.40) (Tables 2 and 4). The average rank on the scale of changes for the countries was as follows (lower values indicate higher changes): Moldova 2.7, Serbia&Montenegro 3.6, Bulgaria 4.3, Croatia 4.3, Greece 5.3, Romania 5.4, Macedonia 5.8, Albania 7.0, Bosnia&Herzegovina 7.1, and Slovenia 7.2). The most stable country was Slovenia where only slight to moderate changes were recorded for all values except for the GDP value which was considerably increased. The global profiles of PH-SEE countries which followed all seven indicators for 1994 (or the nearest available year) and 2002 (or the nearest available year) are indicated in Figures 1 and 2. 4 Discussion 4.1 Selection of the indicators In the selection process of MHIS PH-SEE, specific needs of the PH-SEE countries were assessed. Priorities, measurability in quantitative and qualitative terms, sensitivity to changes and differences, interterritorial comparability, affordability in terms of relative costs, and usefulness for intervention were considered. A detailed description of selection methods is given in the paper by Bardehle (2) and in the final report on the piloting phase (3). 4.2 Results of the study Hospital beds per 100,000 population. There was a notable difference in this indicator among the PH-SEE countries, but it seems to be diminishing. In many PH-SEE countries, a decrease in hospital bed figures was recorded during the period 1994 - 2003. The change was particularly remarkable in Moldova and Bulgaria (Table 2, Figures 1 and 2). In 1994 these two countries had much higher values of this indicator compared to the average EU value (the ratios were 1.78 and 1.48, respectively). The situation may be a result of hospital treatment expansion, which took place all over Europe between 1960 and the beginning of 1980 (20). In Western Europe the process of reducing hospital bed capacity began in 1980s, while in Eastern Europe the expansion persisted and led to a severe crisis in 1990s (20). The reason for the decrease in the number of hospital beds in Moldova and Bulgaria between 1994 and 2003 is not the object of this analysis, but lack of financial resources has been identified as one possible exaplanation. In many PH-SEE countries, the total health expenditure as a percent of GDP spent on health care decreased during this period (Table 3). Another reason seems to be the process of integration of some PH-SEE countries in EU (Greece joined EU several years previously, Slovenia in May 2004, Bulgaria and Romania are supposed to become full members in 2007, Croatia entered the negotiation process in October 2005), which requires adapting to EU standards. In Albania, on the contrary, the value of this indicator was low throughout this period (in 1994 and in 2002 the indicator value was about half the EU-15 average. This observation, together with the data on hospital stay, indicate that Albania is facing serious problems of inadequate health care provision within the hospital sector. Physicians per 100,000 population. The total number of physicians is one of the most important indicators of health care manpower resources (20). To ensure appropriate access to outpatient and inpatient health care services, optimally high figures, as well as continuous slight increases are required (20). Great differences were found between the PH-SEE countries during the period 1994 - 2003. Considerably lower values of this indicator compared to the EU-15 average (with the ratio to the EU-15 of less than 0.50) were recorded at the beginning of the observation period in Albania and Bosnia&Herzegovina (Table 2, Figures 1 and 2). In Croatia, Macedonia, Romania, Serbia & Montenegro and Slovenia the values were somewhat lower, while in Bulgaria, Greece and Moldova they were slightly increased(Table 2, Figures 1 and 2). In 2002 (or the nearest year available) the situation grew worse in Albania and Bosnia & Herzegovina (Table 2, Figures 1 and 2). The most logical explanation for this phenomenon seems to be inadequate health care financing, since the GDP is much below the EU-15 average in most of the PH-SEE countries. Together with low total health expenditure as a percent of GDP, this means extremely low budget for health care. 76 Zdrav Var 2006; 45 Figure 1. Global situation of ratios of selected indicators on health care resources and health care utilization and costs values in the PH-SEE countries to the values of European Union average (EU-15 average, before May 2004) in 1994 or the nearest year available. Comments and abbreviations: * no data available for the total period; f: B&H = Bosnia&Herzegovina, FYR = Former Yougoslav Republic, S&M = Serbia&Montenegro. Slika 1. Razmerje med izbranimi kazalci virov zdravstvene oskrbe ter uporabe in stroškov zdravstvenega varstva v državah mreže PH-SEE in med povprečno vrednostjo za EU (povprečje EU-15 pred majem 2004) 1.1994 (ali najbližje razpoložljivo leto). Komentarji in okrajšave: * za vse obdobje ni podatkov; f: B&H = Bosna in Hercegovina, FYR = bivša jugoslovanska republika, S&M = Srbija in Črna gora. LEGENDA: Indi = Število bolniških postelj na 100.000 prebivalcev, Ind2 = Število zdravnikov na 100.000 prebivalcev, Ind3 = Število splošnih zdravnikov na 100.000 prebivalcev, Ind4 = Število zobozdravnikov na 100.000 prebivalcev, Ind5 = Povprečno trajanje hospitalizacije, vse bolnišnice, Ind6 = Vsi stroški zdravstvenega varstva kot % BDP, lnd7 = BDP, US$ na prebivalca. Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 77 Figure 1. Global situation of ratios of selected indicators on health care resources and health care utilization and costs values in the PH-SEE countries to the values of European Union average (EU-15 average, before May 2004) in 2002 or the nearest year available. Comments and abbreviations: * no data available for the total period; †: B&H = Bosnia&Herzegovina, FYR = Former Yougoslav Republic, S&M = Serbia&Montenegro. Slika 1. Razmerje med izbranimi kazalci virov zdravstvene oskrbe ter uporabe in stro{kov zdravstvenega varstva v dr‘avah mre‘e PH-SEE in med povpre~no vrednostjo za EU (povpre~je EU-15 pred majem 2004) l.2002 (ali najbli‘je razpolo‘ljivo leto). Komentarji in okraj{ave: * za vse obdobje ni podatkov; †: B&H = Bosna in Hercegovina, FYR = biv{a jugoslovanska republika, S&M = Srbija in ^rna gora. LEGENDA: Ind1 = [tevilo bolni{kih postelj na 100.000 prebivalcev, Ind2 = [tevilo zdravnikov na 100.000 prebivalcev, Ind3 = [tevilo splo{nih zdravnikov na 100.000 prebivalcev, Ind4 = [tevilo zobozdravnikov na 100.000 prebivalcev, Ind5 = Povpre~no trajanje hospitalizacije, vse bolni{nice, Ind6 = Vsi stro{ki zdravstvenega varstva kot % BDP, Ind7 = BDP, US$ na prebivalca. 78 Zdrav Var 2006; 45 Another reason may be the escape of young people from health professions to more remunerative professions in economy business, but this theory needs to be verified. General practitioners per 100,000 population. This indicator reflects the provision with primary health care (PHC) resources in a country. Great differences in this indicator were found between the network countries. In comparison to the EU-15 average, at the beginning of the observation period the situation was considerably unfavourable in Bosnia&Herzegovina, Moldova, and Slovenia (with the ratio to the EU-15 of less than 0.50) (Table 2, Figures 1 and 2). It improved in Moldova and was slightly better in Slovenia, but slightly deteriorated in Bosnia&Herzegovina. It seems that health care systems in many of the PH-SEE countries are faced with a relative surplus of highly specialized physicians and shortage of properly trained GPs and family doctors. This is a matter of concern since GPs and nurses represent professions which are the hub of the PHC services network (20). Such situation is likely to create serious problems: highly specialized physicians are primarely interested in the curative approach rather than in combining it with the preventive one. In order to ensure that the supply of health care personnel will meet their needs, most countries have to provide capacities for planning their future human resource requirements more properly. Dentists per 100,000 population. The number of dentists is also of great importance for the PHC, as dental medicine represents an important part of the community-oriented PHC sector (20). As compared to the EU-15 average this values in the PH-SEE countries at the beginning of the observation period showed a considerably unfavourable situation in Bosnia & Herzegovina and Romania (with the ratio to the EU-15 less than 0.50) (Table 2, Figures 1 and 2), which became even worse at the end of the study. The values for Bulgaria exceeded slightly the EU-15 average, but this finding may be due to different definition of a dentist (3). Much higher values were reported in Greece. Average length of hospital stay, all hospitals. During the period 1994 - 2003, the average length of hospital stay was decreasing in most PH-SEE countries, indicating that they followed the average EU trend (Table 3, Figures 1 and 2), The only exception was Serbia&Montenegro where this indicator increased. Reduced hospital bed capacities coupled with shorter hospital stay represent another mechanism for rationalizing the use of secondary and tertiary health care. During the past decades the number of overnight hospital stays in Europe has been reduced, and other settings, such as day-care hospitals, short-stay hospitals, and hospitals providing outpatient care have been established. Nevertheless, the average hospital stay in Eastern European countries is much longer than in the Western Europe (20). This indicator can also be used for assessing cost-effectiveness of the use of available HCR, and therefore shows that health care systems in the Eastern Europe, which is less economically developed , are also less efficient. On the other hand, this situation seem to reflect an arising problem. In 2000, Albania reported the lowest value for this indicator, which suggests absolute lack of hospital beds rather than only the process of general rationalization of health care use. This hypothesis has not yet been verified, but is indirectly supported by the total number of hospital beds for this country (Table 1). Different morbidity structure plays an important role in the assessment of this indicator, but this was not the object of our study. Total health expenditure as a percent of gross domestic product (GDP). This indicator shows what proportion of the GDP can be spent on health care in a country, and largely depends on its economic status. The availability of financial resources required to operate health care services cannot be specified in absolute terms. The amount should be affordable by the country and high enough to meet the needs of health promotion, disease prevention and provision of effective and high-quality curative health care. HEALTH 21 states that 7 - 10% of the GDP population might provide a reasonable amount for a reasonable development of the capacity and performance of a health system if the overall GDP level is adequate (20). Unfortunately, during the period 1994 - 2003 the absolute level of public spending on health care in some of PH-SEE countries was too low to meet even the minimal requirements of the population,; the GDP was extremely low and so was the total health expenditure as a percent of GDP (Table 3, Figures 1 and 2). At the end of observation period, in five PH-SEE countries (Albania, Bulgaria, Macedonia, Moldova and Romania, Kosovo) the value of this indicator was below the suggested minimum. The situation was especially unfavourable in Albania and Kosovo. In addition, an alarming decrease was recorded in Moldova, where the value was halved. The solution is not easy to foresee because of the low economic power of these countries (Table 3). The profiles of the PH-SEE countries. The results of our study globally indicate that Slovenia was the most Bardehle D., Laaser U., Zaletel-Kragelj L. Selected indicators of health care resources, and health care utilization and costs ... 79 stable PH-SEE country during the observed period, while Moldova experienced the most rapid changes. When comparing the results of the PH-SEE countries to the EU-15 average in 2002, it is hard to say which country has come closest to that value. Croatia, Greece and Slovenia has similar values for several indicators(Figure 2). 4.3 Comparison with other studies Comparison with other studies was not possible because the study is currently unique in this part of Europe. 4.4 Strenghts and limitations of the study The strength of this study is that it provides a valuable assessment of the availability of indicators from the MHIS PH-SEE list. The results of the study may serve as an incentive for a more regular reporting in some countries. It is also a very first attempt to investigate indicators of HCR and HCUC in the PH-SEE network countries. These indicators may prove useful in the future development of this underprivileged part of Europe, especially in the field of PH and policies, which should be addressed in the light of EU enlargement in the near future. However, our study has some limitations. The main drawback is the lack of data on some indicators, which impeded the comparison of some indicators , such as “total health expenditure as a percent of GDP” and “GDP in US$ per capita”. This first description of country profiles, however, is of great value to the future process of the SEE countries approaching to each other. Another drawback , although only a temporary one, is that not all indicators required for monitoring HCR and HCUC are currently included in the MHIS PH-SEE. For monitoring health care services two indicators were selected during the selection process (2): “the number of PHC units” and “the number of hospital beds”, both per 100,000 population. The rationale was that health care services, especially those supplied by the PHC units, are extremely important for the health of the population. In many situations they represent a cost-effective alternative to expensive hospital facilities (the running costs for hospitals are much higher than those for PHC units because of high costs of infrastructure and staff maintenance). Unfortunately, the feasibility study (3) showed that the indicator of the number of PHC units failed to meet the data quality standard (the PH-SEE countries do not use the same definition of PHC unit) and was temporarily removed from the MHIS PH-SEE list. The indicator “nurses graduated per 100,000 population” in the set of HCUC indicators was agreed to be included. The rationale behind this decision was that human resources are one of the most important factors in quality health care services. The key health professionals are those working in PHC units, primarily physicians, especially specialists of family medicine, and nurses (20). The feasibility study (3) showed that the indicator “number of nurses graduated” failed to meet the standard of at least acceptable data availability, and was therefore temporarily removed from the MHIS PH-SEE list. 4.5 Necessary steps in the near future In the near future, different aspects of the definition of several indicators presented in this study should be reassessed. Some of them are not clear enough ; e.g. the indicator “number of hospital beds“, does not specify whether private hospital beds are included, and the indicator “ number of physicians and GPs“ does not make it clear whether private sector physicians/GPs are included. The indicator of dentists poses problems related to the changed definition. The newest WHO definition requires university degree for dentists, but in some countries this definition has been used only for the past few years. 5 Conclusions The results of the present study revealed great differences between individual PH-SEE countries in the field of HCR and HCUC, and showed that these discrepancies have been increasing in many respects. Countries on one side of the spectrum, such as Croatia, Greece and Slovenia, are in many respects close to the EU-15 average, while other countries, e.g. Albania, are confronted with all consequences of low economic power. Yet, the situation seems to be improving in these countries too. Between the two poles there is a pallet of different situations. The results stress the need for enhancing mutual help between countries within the PH-SEE network, and for encouraging member countries to share their experience. References 1. Public Health Collaboration in South Eastern Europe, Programmes for Training and Research in Public health-PH-SEE. [homepage on the Internet]. Zagreb: Andrija Stampar 80 Zdrav Var 2006; 45 School of Public Health; 2001. Available from: URL: http:// www.snz.hr/ph-see. Accessed: October 21, 2005. 2. Bardehle D. Minimum health indicator set for South Eastern Europe. Croat Med J 2002; 43: 170-3. 3. Zaletel-Kragelj L, Bardehle D, Laaser U. Minimum health indicator set for PH-SEE countries. Final Report. Bielefeld: Stability Pact - Public Health Collaboration in South Eastern Europe and Institute of Public Health of North Rhine-Westphalia; 2003. Available from: URL: http://www.snz.hr/ph-see/ documents.htm. Accessed: October 21, 2005. 4. World Health Organization, Regional Office for Europe. Health21: the health for all policy framework for the WHO European Region. Copenhagen: WHO Regional Office for Europe (European Health for All Series; No.6); 1999. 5. World Health Organization, Regional Office for Europe. WHO HFA indicators for the new health policy in Europe. Report on a WHO Expert Group Meeting The Hague, Netherlands 2–3 March 2000. WHO Regional Office for Europe, 2000. 6. ECHI Project Group. Public health indicators for Europe: Context, selection, definition. Final report by the ECHI project phase II. Bruxelles: European Commission, 2005. http://www.europa.eu.int/comm/health/ph_projects/2001/ monitoring/fp_monitoring_2001_frep_08_en.pdf. Accessed: October 21, 2005. 7. ECHI Project Group. Annex 5 to the ECHI-2 report 2005.The ECHI comprehensive indicator list (long list). Version of july 7, 2005. Available from: URL: http://www.europa.eu.int/comm/health/ph_information/ indicators/docs/longlist_en.pdf. Accessed: October 21, 2005. 8. World Health Organization, Regional Office for Europe. Health for All Statistical Database. Copenhagen: WHO Regional Office for Europe, 2003. Available from: URL: http://www.who.dk/hfadb. Accessed: June 28, 2003. 9. World Health Organization, Regional Office for Europe. Health for All Statistical Data-base. Copenhagen: WHO Regional Office for Europe, 2005. Available from: URL: http://www.who.dk/hfadb. Accessed: October 21, 2005. 10. Besim Nuri. In Tragakes E. edt. Health care systems in transition: Albania. Copenhagen: European Observatory on Health Care Systems, 2002. 11. Cain J, Duran A, Fortis A, Jakubowski E. In: Cain J, Jakubowski E, eds. Health care systems in transition: Bosnia and Herzegovina. Copenhagen: European Observatory on Health Care Systems, 2002. 12. Koulaksazov S, Todorova S, Tragakes E, Hristova S. In: Tragakes E, edt. Health care systems in transition: Bulgaria. Copenhagen: European Observatory on Health Care Systems, 2003. 13. The European Observatory on Health Care Systems. Health care systems in transition: Croatia. Copenhagen: European Observatory on Health Care Systems, 1999. 14. The European Observatory on Health Care Systems. Health care systems in transition: Greece. Copenhagen: European Observatory on Health Care Systems, 1996. 15. The European Observatory on Health Care Systems. Health care systems in transition: the former Yugoslav Republic of Macedonia. Copenhagen: European Observatory on Health Care Systems, 2000. 16. MacLehose L. In: McKee M, edt. Health care systems in transition: Republic of Moldova. Copenhagen: European Observatory on Health Care Systems, 2002. 17. The European Observatory on Health Care Systems. Health care systems in transition: Romania. Copenhagen: European Observatory on Health Care Systems, 2000. 18. Albreht T, Cesen M, Jakubowski E, et al. In: Jakubowski E, eds. Health care systems in transition: Slovenia. Copenhagen: European Observatory on Health Care Systems, 2002. 19. Campbell J, Percival V, Zwi A. Post-conflict, post-election issues in Kosovo´s health sector. Eur J Public Health 2003; 13: 177-81. 20. World Health Organization, Regional Office for Europe. An outcome-oriented health sector. In: World Health Organization, Regional Office for Europe. Health21: the health for all policy framework for the WHO European Region. Copenhagen: WHO Regional Office for Europe (European Health for All Series; No.6); 1999: 115-146. Zdrav Var 2006; 45: 81-89 81 ATTITUDES OF SLOVENE GENERAL PRACTICE TRAINERS TO THE IMPLEMENTATION OF PREVENTIVE ACTIVITIES ODNOS MENTORJEV SPLO[NE MEDICINE DO IZVAJANJA PREVENTIVNIH DEJAVNOSTI Mateja Bulc1,2 Prispelo: 17. 2. 2005 - Sprejeto: 30. 1. 2006 Original scientific article UDC 616-084 Abstract Aim: To determine the knowledge of and the attitudes of Slovene general practitioners (GPs) to evidence-based health promotion and disease prevention, to identify perceived barriers to the implementation of recommendations, and to assess how GPs’ own health behaviors affect their work. Methods: This study was a part of the multinational EUROPREV (European Network for Prevention and Health Promotion in Family Medicine and General Practice) survey. In 2000/2001 a postal survey was conducted in a sample of GPs from national colleges of each EUROPREV member country. In summer 2000, 100 Slovene general practice/family medicine (GP/FM) tutors were sent EUROPREV questionnaires assessing their attitudes towards preventive services in general practice and towards their own lifestyles. Results: The response rate was 55%. Slovene GPs are well aware of the need to provide preventive and health promotion services, but in practice, they are less likely to do so. A total of 62% of respondents found it difficult to implement disease prevention and health promotion programmes. Heavy workload and lack of time (93%), as well as lack of incentive (35%) were the two most important barriers reported Conclusions: A significant discrepancy between GPs’ knowledge and practice was found as concerns the use of evidence-based recommendations for health promotion and disease prevention in Slovene primary care. Key words: attitudes, prevention, health promotion, general practice, Slovenia Izvirni znanstveni ~lanek UDK 616-084 Izvle~ek Cilji: Ugotoviti, kak{no je poznavanje in odnos slovenskih splo{nih zdravnikov do preventivnih dejavnosti in dejavnosti za krepitev zdravja, podprtih z dokazi; opredeliti ovire, ki jih do‘ivljajo pri izvajanju priporo~enih dejavnosti in ugotoviti, kako njihove lastne zdravstvene navade vplivajo na njihovo delo. Metode: Raziskava je del mednarodnega projekta EUROPREV (Evropska mre‘a za prepre~evanje bolezni in krepitev zdravja v dru‘inski medicini in splo{ni praksi). V letih 2000/2001 je potekala anketa, ki je zajela vzorec dru‘inskih zdravnikov nacionalnih univerz vseh dr‘av ~lanic mre‘e EUROPREV. Poleti leta 2000 je sto slovenskih tutorjev splo{ne/dru‘inske medicine prejelo vpra{alnik EUROPREV o odnosu do preventivnih dejavnosti v splo{ni praksi in do lastnih zdravstvenih navad. Rezultati: Odgovorilo je 55 % vpra{anih. Slovenski splo{ni zdravniki se dobro zavedajo nujnosti prepre~evanja bolezni in krepitve zdravja, vendar je ta slika v praksi druga~na. Dvain{estdeset odstotkov anketiranih je menilo, da je delo na podro~ju prepre~evanja bolezni in krepitve zdravja zahtevno. Najve~krat navedene ovire v anketi so bile delovna obremenitev in pomanjkanje ~asa (93%) ter pomanjkanje pobud (35%). 1 Health Centre Ljubljana, Ljubljana-[i{ka Department, Der~eva 5, 1000 Ljubljana 2 University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana Correspondence to: e-mail: mateja.bulc@email.si 82 Zdrav Var 2006; 45 Zaklju~ki: Pri uresni~evanju z dokazi podprtih priporo~il za krepitev zdravja in prepre~evanje bolezni v osnovnem zdravstvu se je pokazala velika neskladnost med znanjem splo{nih zdravnikov in njihovim prakti~nim delom. Klju~ne besede: odnos, preventiva, promocija zdravja, splo{na praksa, Slovenija Introduction Cardiovascular diseases are the major cause of early death in developed countries; they are an important cause of morbidity and invalidity, and of increased health care costs (1). Guidelines and recommendations on prevention, identification and control of arterial hypertension focus on lifestyle risk factors and patients’ health behaviour (2 - 3). Elimination of lifestyle-related risk factors is extremely important not only in patients but also in “healthy” individuals at high cardiovascular risk (4). As it is not possible to influence biological risk factors (gender, age and family history), primary health care physicians are supposed to focus on lifestyle risk factors, including unhealthy diet, physical inactivity, smoking, risky alcohol consumption and overweight (5). These are the most important issues that should be addressed through public health policy and medical interventions (1). Cardiovascular diseases are the major cause of early death in developed countries; they are an important cause of morbidity and invalidity, and of increased health care costs (1). Guidelines and recommendations on prevention, identification and control of arterial hypertension focus on lifestyle risk factors and patients’ health behaviour (2 – 3). Elimination of lifestyle-related risk factors is extremely important not only in patients but also in “healthy” individuals at high cardiovascular risk (4). As it is not possible to influence biological risk factors (gender, age and family history), primary health care physicians are supposed to focus on lifestyle risk factors, including unhealthy diet, physical inactivity, smoking, risky alcohol consumption and overweight (5). These are the most important issues that should be addressed through public health policy and medical interventions (1). Nowadays general practitioners (GPs) and family physicians provide services to autonomous individuals across the fields of prevention, diagnosis, cure, care and palliation, using and integrating the sciences of biomedicine, medical psychology and medical sociology. Two-thirds of the population in most European countries visit their GP at least once a year, and 90% at least once in five years. GPs are therefore in an excellent position to administer age- and sex-specific preventive and health promotion packages. These services are provided either in an opportunistic manner, i.e. when patients attend for any reason, or as planned services, i.e. as a part of scheduled, evidence-based preventive programmes (4). However, there are differences in the structure and organization of practice in European countries, which vary largely in the degree of involvement of general practitioners in preventive activities. In Slovenia the Countrywide Integrated Non-communicative Disease Intervention (CINDI) programme has been adopted as one of the strategies targeted at lifestyle modification (5-9). It was developed by the World Health Organization (WHO) with the aim of preventing chronic diseases. It focuses on risk factors that contribute to the development of chronic non-communicable diseases. By assessing risk factors in the targeted population using standardized methodology the global cardiovascular risk is being modified. Each member country has to determine the prevalence of risk factors in the population of a given geographical area, assess the cardiovascular risk and intervene according to the risk (4). Public health authorities participated in the intervention by launching national information campaigns, by supporting healthy lifestyle modifications, using political interventions, such as strict legislation against smoking in public places and smoking advertising, along with campaign guidance to achieve and maintain smoking cessation in the population (4). Significant changes have occurred in Slovenia in the field of prevention and health promotion over the past ten years. A group of enthusiastic general practitioners in the Ljubljana Health Centre joined the WHO-CINDI programme 15 years ago (5-7). Three survey studies on a random sample of adult Ljubljana inhabitants were performed to determine the prevalence of risk factors and assess the global cardiovascular risk. As the global risk levels were high, interventions had to be introduced following the WHO-CINDI directive (10). Health education programmes for physicians and nurses were designed Bulc M. Attitudes of Slovene general practice trainers to the implementation of preventive activities 83 and implemented. Interventions against unhealthy behavior patterns were initiated in 1992; they were targeted both at the entire country’s population (nearly 2 million), and at individual high-risk patients (8). In recent years health promotion has emerged as an increasingly important segment of primary health care in Slovenia (6 - 9). This trend is part of a movement towards the integration of public health responsibilities into general practice. Primary health care teams had to assume new strategic responsibilities. Responsibility for maintaining and promoting the health of patients on the practice list was entrusted to GPs by the 2001 GPs’ contract (9). It incorporates the following elements: • population monitoring through health surveillance; • regular health checks for adults; and • setting up of health promotion centres. In spite of all these facts, the provision of disease prevention and health promotion services posed considerable difficulties to the practicing physicians in Slovenia. The results of the study clearly confirm considerable disparity between the GP tutors’ knowledge and practice of preventive services. The objective of this cross-sectional epidemiological study was to explore the knowledge of and attitudes of Slovene GPs towards the implementation of evidence-based health promotion and disease prevention recommendations in primary care, to describe GPs’ perceived barriers to implementing these recommendations, and to assess the participants’ self-reported health behavior. Methods Participants The data were collected by a postal survey as part of the 2000/2001 EUROPREV (European Network for Prevention and Health Promotion in Family Medicine and General Practice) survey (11). The required sample size per country was calculated by EUROPREV. The survey instrument and an addressed stamped return envelope were mailed to 100 Slovene GPs, tutors in general practice/family medicine from June to August 2000. GPs for the survey were recruited by the Department of Family Medicine of the Faculty of Medicine, University of Ljubljana. To become GP/FM tutors in Slovenia, physicians are required to be specialists in GP/FM and must have participated at least once in two years in the annual workshop organized by the Department of Family Medicine and European Academy of Teachers in GP/FM (EURACT). Method The EUROPREV network developed and pre-tested a questionnaire, which was piloted with ten GPs, using a pre-paid addressed envelope. For the Slovene survey, the original EUROPREV questionnaire was translated from English to Slovene, and adapted for use in Slovenia. It consisted of four sections. The first section had questions designed to collect demographic and professional data on participants (11). The second part of the questionnaire contained two clinical scenarios: one presenting a 52-year-old male, and another a 57-year-old female, who visited their GP with a trivial health problem and had had no previous check-ups or tests. GPs were asked to mark: a) preventive activities that should be performed, and b) preventive activities that they actually perform in their clinical practice. The third section of the questionnaire asked GPs’ about their perception of the delivery of preventive and health promotion services, and about barriers to the implementation of these programmes. The fourth section had questions on the participants’ health behaviours. Statistical analysis All the returned questionnaires were sent back to the co-coordinating and data management centre of the EUROPREV headquarters in Barcelona, Spain, to assure centralised data entry and analysis. The mean and standard deviations for continuous variables and percentages for categorical variables were computed. All analyses wered one using the STATA programme (version 5.0). Results The response rate in Slovenia survey was 55.0%. Sex distribution of respondents (Table 1) did not differ considerably from that in the total population in Slovenia (12). The mean age of participating physicians was 46 to 59 years (SD ± 6.43). Their professional characteristics are shown in Table 2. Responses to both scenarios disclosed a disparity between GPs’ knowledge of and practice towards risk factors, with the exception of blood pressure control (Table 3), as well as a difference in their attitudes towards male and female patients. Nearly all participants checked blood pressure in the male scenario, but only two-thirds did so in the female case vignette. The same proportion of respondents checked serum cholesterol and blood glucose in both case 84 Zdrav Var 2006; 45 Table 1. Gender characteristics of the Slovene population and tutors-respondents (N=55). Tabela 1. Prebivalci Slovenije in anketirani tutorji po spolu (N=55). Population of Slovenia / Prebivalci Slovenije 31.12.1999 % Respondents / Anketiranci 1. 9.2000 % Men / Moški 49 Men / Moški 43,6 Women / Ženske 51 Women / Ženske 56,4 Table 2. Professional characteristics (in %) of Slovene tutors-respondents (N=55). Tabela 2. Poklicne zna~ilnosti anketiranih slovenskih tutorjev (v %) (N=55). Characteristics /Značilnosti % Urban practice / Delo v mestu Rural practice / Delo na podeželju Mixed / Mešano 40,7 25,9 33,3 Employed / Zaposleni Private (»solo« practice) / Zasebniki Other / Drugo 65,5 25,5 9,0 Public health care institution / Javnozdravstvena ustanova Private health care institution / Zasebna zdravstvena ustanova 67,3 32,7 Postgraduate teaching activities / Podiplomski pouk 94,4 vignettes. In the male scenario, screening for colon cancer was reported by half of the participants, and in the female scenario by 11%. The use of chest X-ray as a screening test in male patients was reported by 29% of GPs. Only one third of GPs inquired about their patients’ immunisation status, but moreof them were interested in their patients’ health behaviour: nearly all checked smoking, and three-thirds advised smokers to quit. Alcohol intake in men was not strictly checked; two-thirds of GPs advised risky drinkers to reduce alcohol consumption or stop drinking. In male patients, body weight and height were measured by less than one half of the participants, and in females by more than one half; overweight patients were advised to loose weight. Physical activity was inquired after by three-fourths of GPs; two thirds of them also advised physically inactive patients to change their lifestyle. Screening for cervical cancer was recommended by one half of GPs. Table 4 shows the perceived causes of poor prevention and health promotion, focusing on the differences in the perceived barriers. The EUROPREV study showed that more than half of Slovene GP tutors found it difficult to perform preventive checkups and cardiovascular risk assessment in their patients, and the reportedly felt minimally effective, or ineffective in helping patients change unhealthy lifestyles, especially in advising them to take up regular physical activity. The main barrier reported was heavy workload and lack of time (Table 5). GPs’ self-reported state of health and health-related habits are shown in Table 6. Bulc M. Attitudes of Slovene general practice trainers to the implementation of preventive activities 85 Table 3. Responses of Slovene tutors-respondents (N=55) to the male and female clinical scenario. Tabela 3. Odgovori sodelujo~ih slovenskih tutorjev na vpra{anja v ‘enskem in mo{kem klini~nem scenariju (N=55). Risk factor assessment/ Male patient / Bolnik Female patient / Bolnica Ocena dejavnikov tveganja Should it be Do I dO it? Should it be done Do I dO it? done (yes as %) / (yes as %) / Je to (yes as %) (yes as %) / Je to Ali to storim? treba storiti? /Alito treba storiti? (da (dav%) (da v %) storim? v%) (da v %) Measure cholesterol level / Določanje ravni holesterola a/,3 /¦4,0 B/,3 iz,/ Measure blood pressure / Merjenje krvnega tlaka 96,4 94,6 98,2 89,1 Measure glucose level / Določanje ravni sladkorja au,a /lofi 9B,4 f4,e Inquire on smoking 100,0 95,4 100,0 86,7 Advise smokers to quit / 100,0 72,7 96,4 74,6 Vprašanja o kajenju Nasvet bolniku naj opusti kajenje Inquire on alcohol consumption '98,2 74,4 100,0 68,2 Vprašanja o pitju alkohola 63,6 96,4 63,6 Advice risky drinkers to reduce consumption 96,4 Svetovanje tveganim pivcem, naj omejijo pitje alkohola BMI measurement / Izračun indeksa telesne mase Diet advice / Prehransko 96,4 70,9 98,2 72,7 svetovanje Inquire on physical activity/ 96,3 74,4 96,3 71,1 Vprašanja o telesni dejavnosti Advice sedentary patients to Increase activity / Svetovanje bolnikom, ki pretežno sedijo, naj bodo bolj telesno dejavni Tetanus immunization / Cepljenje proti tetanusu Screening for colon cancer - occult blood test 47,2 18,8 42,3 11,1 colonoscopy 13,2 6,4 9,8 6,7 Presejanje za raka debelega črevesa - pregled blata na okultno krvavitev Koloskopija Screening for breast cancer - mammography / Presejalni test 78,2 54,6 za raka dojk - mamografija Screening for cervical cancer 78,2 50,9 with Pap smear / Presejalni test za raka materničnega vratu- odvzem brisa Pap Prostate cancer screening 78,2 56,4 (RDE /PSA) / Presejalni test za raka prostate (RDE /PSA) Lung cancer screening (X ray) / 38,2 29,1 Presejalni test za pljučnega raka - rentgensko slikanje BMI: body mass index / indeks telesne mase RDE: rectal digital examination / digitalna rektalna preiskava PSA: prostate specific antigen / specifi~ni prostati~ni antigen 86 Zdrav Var 2006; 45 Table 4. Perceptions of Slovene tutors-respondents (N=55) of their implementation of disease prevention and health promotion. Tabela 4. Kaj menijo anketirani tutorji (N=55) o svojem izvajanju dejavnosti za prepre~evanje bolezni in promocijo zdravja. Activity / Dejavnost Yes as %/Da v% Carrying-out prevention and health promotion is 61,8 % difficult / Preventivne dejavnosti in dejavnosti za krepitev zdravja so zahtevna naloga Minimally effective or ineffective in helping patients 41,8% reduce tobacco use / Minimalna učinkovitost oz. neučinkovitost pri prizadevanjih za omejevanje kajenja pri bolnikih Minimally effective or ineffective in helping patients 56,4% reduce alcohol consumption / Minimalna učinkovitost oz. neučinkovitost pri prizadevanjih za zmanjševanje pitja alkohola pri bolnikih Minimally effective or ineffective in helping patients 54,6% achieve or maintain normal weigh / Minimalna učinkovitost oz. neučinkovitost pri prizadevanjih za pridobitev oz.vzdrževanje normalne telesne teže pri bolnikih Minimally effective or ineffective in helping patients 25,9% practice regular physical exercise / Minimalna učinkovitost oz.neučinkovitost pri prizadevanjih za povečanje telesne dejavnosti pri bolnikih Table 5. Slovene tutors-respondents’ (N=55) perceptions of barriers to implementing health promotion and preventive activities (non-exclusive answers). Tabela 5. Kaj menijo anketirani slovenski tutorji o ovirah pri izvajanju preventivnih dejavnosti in dejavnosti za krepitev zdravja (N=55). Barrier / Ovira Yes as % /Da v % Heavy work load and lack of time / Velike delovne obremenitve in pomanjkanje časa No reimbursement / Neustrezno nagrajevanje Patients' accessibility / Dostopnost bolnikov Lack of consensus (discrepancies in the recommendations) / Neenotnost in neusklajenost priporočil Patients' doubts about effectiveness / Bolnikovi dvomi o učinkovitosti Lack of clarity on which professional in primary care is responsible / Nejasnost pri opredelitvi odgovornosti v primarnem zdravstvu Insufficient personal training in prevention and health promotion / Nezadostna usposobljenost za preventivno dejavnost in krepitev zdravja 92,7 34,6 20,0 20,0 14,6 25,5 10,1 Bulc M. Attitudes of Slovene general practice trainers to the implementation of preventive activities 87 Table 6. Slovene tutors’-respondents’ ( N=55) state of health and health behaviour. Tabela 6. Zdravstveno stanje in zdravstvene navade anketiranih slovenskih tutorjev (N=55). Risk factor / Dejavnik tveganja Yes as % / Da v % Elevated serum cholesterol / Povišana raven holesterola 40,0% High blood pressure (BP) / Povišan krvni tlak 21,8% Smoking cigarettes / Kajenje - cigarete 9,1% Cigars / Cigare 1,8% Risky alcohol use / Tvegano pitje alkohola 3,7 % Regular physical activity in leisure time / Redna telesna dejavnost v prostem času 60,0% Immunised Influenza / Cepljenje proti gripi 49,1% Hepatitis B / proti hepatitisu B 69,1% Tetanus / proti tetanusu 80,0% High risk of colon cancer / Povečano tveganje za raka debelega črevesa 9,1% Screened for colon cancer / Opravljen presejalni test za raka debelega črevesa 10,7% MALES / MOŠKI Prostate symptoms / Težave s prostato 3,5% Screened for prostate cancer-/ Opravljen pregled za raka prostate digital rectal examination PSA /digitalni rektalni pregled PSA 25,0% 41,7% FEMALES/ŽENSKE Breast cancer risk/Tveganje za raka dojke 16,1% Mammography performed / Opravljena mamografija 34,6% Cervical cancer risk /Tveganje za raka materničnega vratu 0,0% Screened (PAP smear) / Odvzet bris po Papanicolauu 8,1% Legend: / Legenda Risky alcohol drinking: > 2 units/day for male and > 1 unit for female participants / Tvegano pitje alkohola > 2 merici na dan za mo{ke in > 1 merica za ‘enske Regular physical activity: activity daily or two to three times a week. / Redna telesna dejavnost: dejavnost vsak dan ali dva - do trikrat na teden Immunised: every year or only some years / Cepljeni: vsako leto ali le v nekaterih letih Risk of colorectal cancer was considered to be increased in persons with tubular adenomas of >1 cm, villous or tubulovillous adenomas of any size, hereditary gastrointestinal polyposis syndromes, personal or familial history (first degree) of colorectal cancer, endometrial cancer, ovarian cancer, ulcerative colitis of more than 8-10 years of evolution for extensive forms (pancolitis) or more than 15 years of evolution in ulcerative colitis of the left colon / Pove~ano tveganje za kolorektalnega raka: tubulni adenoma, ve~ji kot 1 cm, vilozni ali tubulno-vilozni adenomi, ne glede na velikost, familiarna polipoza ~revesa, osebna ali dru‘inska anamneza kolorektalnega raka (1. stopnja), rak endometrija, rak jaj~nikov, ulcerozni kolitis, ki se je razvijal ve~ kot 8-10 let (pankolitis), ali ve~ kot 15 let (ulcerozni kolitis levega dela debelega ~revesa) Prostate cancer screening: at least one screening test carried out / Presejanje za raka prostate: opravljen vsaj en presejalni test Breast cancer risk: increased in persons with personal or familial (first degree) history of breast cancer (higher risk if it was bilateral or occurred before menopause), precocious menarchy (<12 years old), nulliparity, first pregnancy in advanced age (>30 years), late menopause (>55 years old), hormone replacement therapy, hormonal contraception, obesity, breast ionizing radiations, high alcohol consumption / Pove~ano tveganje za raka dojke: osebna ali dru‘inska (po ‘enski liniji) anamneza raka dojke (tveganje je {e ve~je pri raku na obeh dojkah in pri raku, ki se je razvil pred menopavzo; zgodnja menarha (pred 12. letom starosti), nuliparnost, prva nose~nost po 30. letu starosti, pozna menopavza (po 55. letu starosti), nadomestno hormonsko zdravljenje, hormonska kontracepcija, debelost, ionizirajo~e sevanje, ~ezmerno pitje alkohola Cervical cancer risk: increased with the following factors: tobacco use, low socioeconomic level, precocious sexuality, high number of sexual partners, human papilloma virus infection / Pove~ano tveganje za raka materni~nega vratu: kajenje, slabe socialne in dru‘bene razmere, zgodnja spolnost, veliko {tevilo spolnih partnerjev, oku‘ba s papilloma virusom 88 Zdrav Var 2006; 45 Discussion The extent to which people follow healthy lifestyles varies largely from one country to another (2, 13). EUROPREV is one of the networks, established to obtain and disseminate useful information provided by national associations and institutions to compare not only national health services, but also protocols and guidelines on the issue, and to run research projects, such as the survey described in this paper (11). The European network of GP colleges initiated specific research projects, such as the one involving more than 2000 GPs. As only 55 of the 100 invited Slovene GP tutors participated in our study, the results are not representative of the whole GPs population. The authors would therefore welcome information provided for this survey by other colleagues. The survey respondents are likely to have a more favourable attitude to health promotion than the general GPs population, and as a result the results may have been overestimated because of bias. It is difficult to compare our results with those obtained in other surveys because of different methods used. The answers to the two clinical scenarios show that tutors are well aware of the importance of disease prevention and health promotion services, but that, in practice, they are less likely to provide them to patients presenting with most of the risk factors. One exception seems to be blood pressure measurement, most probably because it has become a routine procedure. Answers to the female and male scenarios indicated that risk factors, except body mass index, were more frequently assessed in men than in women. The participating tutors obviously regarded risk factors in women as minor ones. Spanish authors (13), who evaluated preventive services in general practices, found similar results for counselling, but poorer results for cardiovascular risk assessment. Determining BMI in men was the most rarely reported procedure. This observation suggests that the participating Slovene tutors consider weight, height and BMI measurements in men a waste of time, and regarded testing the success of dietary counselling on overweight and obese patients as a most ungratifying task. The measurements, however, were practised in female patients. Questions about preventive activities that are either ineffective, such as screening for lung cancer, or not evidence-based, such as screening for prostate cancer, were purposefully included in the questionnaire. Surprisingly, nearly 40% of the survey participants answered they performed these tests in male patients, although no current guideline recommends routine screening for lung cancer (with either chest x-rays or sputum cytology) of either the general population or of smokers (14). As concerns prostate cancer screening, there is no clear evidence that survival can be improved by early detection and treatment of the disease. Routine screening for prostate cancer remains a controversial issue, with arguments against and in favour of the test (11). Slovene medical practice guidelines state that screening programmes should be proven to be beneficial before being implemented (8). Among the barriers to disease prevention and health promotion implementation, the two leading causes reported by the 55 participating GP tutors included heavy workload/lack of time and no reimbursement. These were also two of the most important barriers identified by 2,300 GPs participating in a EUROPREV survey (11). More than half of the GPs were sceptical about their ability to help patients reduce risky alcohol drinking, or achieve/maintain normal weight. Other surveys have yielded similar results: Dutch researchers state that counselling in general practice is often targeted at the wrong people, at the wrong time. Improvements can possibly be achieved by making registration of lifestyle parameters in patient records common practice, and by simply asking patients where they stand in respect to lifestyle change (15). Australian GPs compared the efficacy of brief one- minute counseling and counseling lasting ten minutes: in the latter the efficacy increased from 10% to 16% (16). Kreuter realised that successful disease prevention programmes in primary care settings will systematically detect patients who need preventive services, instruct them in the necessity of undertaking preventive activities, and use automated data systems to support and reinforce physician advice and preventive services. Physician advice that primes patients to act on subsequent health information will play an important role in this disease prevention equation (17). The study revealed that nearly half of the participating tutors were at high cardiovascular risk; 40% of them were not physically active on a regular basis, and 40% had high serum holesterol levels. The fact is, however, that the study was conducted during a very busy “transition” period, characterised by radical political and social changes accompanying the transition from state socialism to capitalism in 1991. All those perturbances caused immense changes in lifestyles of the population, Bulc M. Attitudes of Slovene general practice trainers to the implementation of preventive activities 89 and had profound implications for patients’ and physicians’ attitudes towards health (18). Possible limitations of the study were that the questionnaire was too long, that it may have been subject to misinterpretation by the participants and was influenced by changing perceptions of disease prevention and health promotion activities. This seems to have been the reason for low response rate, which is also one of the limitations of the study. On the other hand, the value of the study is that it provided important information about everyday practice of Slovene family medicine tutors. The results of this study stress the need for motivating GP tutors to provide preventive and health promotion activities in line with the adopted guidelines and last evidence. Under the 2002 regulations Slovene general practitioners are required to carry out preventive check-ups in 20% of their adult population, therefore new data are expected to be disclosed by repeat study. Other issues relating to this area should be addressed by the study, such as GPs’ workload and possible changes in GPs’ attitudes towards their own health behaviour. Conclusions 1. The participating family medicine tutors feel minimally effective or ineffective in tackling most risk factors: i.e. in helping patients reduce tobacco use, alcohol consumption and achieve or maintain normal weight. 2. They do not give enough attention to their own health, health -related behavior and screening. 3. Slovene GPs should become more motivated to carry out disease prevention and health promotion activities. 4. Repeat study should be conducted in a few years’ time. Acknowledgements I express my gratitude to all GPs who answered the survey questionnaire and made this study possible in spite of their workload and summer holidays. GP tutors have always been the cornerstone of Slovene family medicine. I am grateful to IVAN ER@EN MD, MSc, for his valuable remarks and corrections. I wish to thank the EUROPREV network for the study protocol and statistical analysis. References 1. Yach D, Hawkes C, Gould CL, Hofman KJ. 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Prev Med 2005; 40(5): 595-601. 12. SURS BSP Statistical Office of Republic of Slovenia. Statistical Databank Online. Ljubljana: Statistical Office of Republic of Slovenia; 2004. URL: http://bsp1h.gov.si/D2300.kom/ komstart.html. 13. Lopez-de-Munain J, Torcal J, Lopez V, Garay J. Prevention in routine general practice: activity patterns and potential promoting factors. Prev Med 2001; 32: 13–22. 14. US Preventive Task Force. US preventive services task force. Guide to clinical preventive services. second ed. Baltimore, MD7 Williams and Wilkins; 1996. 15. Verheijden MW, Bakx JC, Delemarre IC, Wanders AJ, van Woudenbergh NM, Bottema BJ, van Weel C, van Staveren WA. GPs’ assessment of patients’ readiness to change diet, activity and smoking. Br J Gen Pract 2005; 55(515): 452-7. 16. Litt J. Smoking and GPs: time to cough up: successful interventions in general practice. Aust Fam Physician 2005; 34(6): 425-9. 17. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? Evidence for a Priming Effect. Arch Fam Med 2000; 9: 426-33. 18. Zaletel Kragelj L, Er‘en I, Fras Z. Interregional differences in health. Croat Med J 2004; 45: 637-43. 90 Zdrav Var 2006; 45: 90-95 DETECTION AND MANAGEMENT OF DEPRESSION IN SLOVENE FAMILY PRACTICE. A CASE VIGNETTE STUDY UGOTAVLJANJE IN ZDRAVLJENJE DEPRESIJE V SLOVENSKI DRU@INSKI MEDICINI. VINJETA S SIMULACIJO PRIMERA Josip Car1,2, Janko Kersnik1, Igor Švab1, Danica Rotar-Pavli~1 Prispelo: 30. 3. 2005 - Sprejeto: 15. 1. 2006 Original scientific article UDC 616.89(497.4) Abstract Objective: Slovenia is a country with a very high suicide rate, and depression is one of the predisposing factors leading to it. Many studies have shown that depression tends to go unrecognised and undertreated in family medicine. Little is known about the management of depression in Slovene family practice. Method: A nation-wide study using a case vignette was undertaken to determine the strategies adopted by family physicians in the management of depression, and the factors that influence appropriate decision making. A total of 173 family physicians from a national list of 778 physicians working in family practice were approached to take par t in the study. Results: A response rate of 75.4% was achieved. Over 90% of Slovene family physicians recognised a mental health problem in the simulated patient. However, only 61% of them chose appropriate treatment in line with the set criteria. Interestingly, the prescribing strategies are more similar to the American than to the British data. Conclusion: Slovene family physicians are very good at recognising a mental health problem, but less so in selecting the appropriate treatment strategies, which leaves a lot of room for improvement. Key words: family practice, depression, treatment, questionnaires, Slovenia Izvirni znanstveni ~lanek UDK 616.89(497.4) Izvle~ek Namen: Slovenija ima visoko stopnjo umrljivosti zaradi samomorov, pri ~emer je depresija lahko eden vzro~nih dejavnikov. [tevilne raziskave ugotavljajo, da depresivne bolnike v splo{nih ambulantah pogosto spregledamo in jih ne zdravimo ustrezno. Metode: Na naklju~nem vzorcu slovenskih zdravnikov dru‘inske medicine smo preverili ukrepanje ob depresivnem bolniku in odlo~itve glede zdravljenja. Preverili smo tudi dejavnike, ki vplivajo na razlike. Uporabili smo vinjeto s primerom bolnice. K sodelovanju v raziskavi smo povabili naklju~en vzorec 173 zdravnikov splo{ne medicine izmed 778 zdravnikov, kolikor jih je bilo v bazi Zavoda za zdravstveno zavarovanje Slovenije. Rezultati: Odgovorilo je 75,4% anketiranih zdravnikov. Ve~ kot 90% slovenskih zdravnikov je prepoznalo du{evno motnjo pri simuliranem bolniku. Vendar se je pa le 61% zdravnikov odlo~ilo za pravilno ukrepanje. Slog predpisovanja antidepresivov je bolj podoben ameri{kim kot britanskim zdravnikom. Sklepi: Slovenski dru‘inski zdravniki so zelo uspe{ni pri prepoznavanju du{evne motnje, a dosti manj pri izbiri ustreznega zdravljenja, kar daje veliko mo‘nosti za izbolj{ave v prihodnje. Klju~ne besede: dru‘inska medicina, depresija, zdravljenje, ankete, Slovenija 1 University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana 2 Imperial College London, Department of Primary Care and Social Medicine, London Correspondence to: e-mail: josip.car@imperial.ac.uk Car J., Kersnik J., [vab I., Rotar-Pavli~ D. Detection and management of depression in Slovene family practice ... 91 Introduction Depression is a common health problem in the population and a considerable burden for the society. The point prevalence of depressive symptoms is estimated at 13-20% and the prevalence of depressive illness at 2-5% (1). The prevalence of depression among people aged over 65 in the general population is 15% (2). Depression is also a frequent cause of office visits. It has been estimated that 5-10% of the population consult family physicians because of underlying depressive illness in one year (1), and up to 25% of people aged over 65 years (2). Unrecognised and untreated depression is associated with increased suicide rates, and adds to the burden of morbidity associated with physical conditions such as cancer, ischemic heart disease and arthritis (3-5). Thanks to recent advances in therapy, many depressive patients can be effectively managed by their family physicians (6-8). Continuity of care in family practice presents a good opportunity for the detection and effective treatment of depressed patients (9, 10). In spite of that many depressed patients probably still go unrecognised, untreated or inadequately treated (6, 11, 12). Howe found that only 44% of the depressed patients were appropriately diagnosed in general practice (13). Kessler and co-workers reported that only 36% of depressed patients were recognised by the family physicians (14). The observed variation in the management of depression in family practice poses additional problems (15, 16). Routine mortality statistics show that suicide rates in Slovenia are among the highest in Europe, and that mental health services in general face many difficulties in meeting the challenge posed by the mental health needs of the population (17, 18). These findings and other data suggest that depression is one of the challenging problems, which is inadequately addressed in primary care (19). We undertook a national survey to assess the detection and management of depression by family physicians (20). Material and Methods Sample A cross-sectional study was conducted on a representative sample of Slovene family physicians. A random sample of 198 family physicians from the national list of 778 (25.5%) physicians working in family practice were asked to participate: 16 were not available because they had changed their careers, six were retired and three were on a maternity leave. The remaining 173 participants were either approached by telephone by one of the researchers (JC) (100 participants), or personally by tutors affiliated to the Department of Family Medicine, University of Ljubljana (73 participants). The purpose of the study was explained to them, and only two refused to participate. The age and gender of the participants, the type of practice (public service versus private practice) and the regional distribution of the 171 practices were matched with the national data. The sample did not differ from the national data. Questionnaire The questionnaire had two sections: • Questions about the characteristics of the physician and his/her practice (demographic characteristics, working hours per week, hours of CME yearly, number of inhabitants served by the office, training, years in the practice, type of practice (solo or group practice), number of patients on the list, number of patients seen daily, number of home visits weekly, number of phone calls daily, use of appointment system, and availability of the psychiatric services) • A case vignette describing an elderly woman suffering from depression, which was pre-tested in a pilot study and checked by three referee psychiatrists, was included in the questionnaire (see Appendix). The participants were asked to respond to the following yes/no and consecutive open-ended questions on disease management: 1. Would you refer the patient to a specialist? (y/n) If yes, to which one? 2. Would you prescribe medicine(s)? If yes, which one(s)? 3. Would you give the patient any counselling/advice? If yes, what advice? 4. Would you make an appointment arrangement for a follow-up visit in your office? If yes, in how many days? Statistical Analysis The data were entered into the computer and analysed using SPSS for Windows software. Descriptive statistics were calculated. The Student t-test and chi square test were used according to the type of variables (where needed, Fisher’s Exact Test was calculated). The following decisions were required for the treatment 92 Zdrav Var 2006; 45 to be considered adequate, i.e. appropriate measure: • Choosing an antidepressant and/or referring the patient to the psychiatrist • Scheduling a follow-up appointment • Adding an anxiolytic drug to the antidepressant was regarded as justified but not mandatory Those, who did not follow these decisions, were regarded as providing inappropriate care or failing to recognise depression. For group comparisons, the participating family physicians were assigned to categories according to the size of their patient list (cut point 1,500 persons on the list,i.e. the average list size in Slovenia) and part/ full time working pattern. Results We received 129 (75.4%) out of the 171 completed questionnaires. The analysis of non-respondents (42%) did not show any significant differences in age, gender, regional distribution or training of the participating family physicians. Eighty (46.6%) respondents were males, the mean age was 44.9 years; 55 (42.6%) participants had completed training, the mean time elapsed since training was 11 years. The participants spent on average eight days a year on Continuing Medical Education; the average time in practice was 16 years; the majority, i.e. 109 (63.8%) shared their premises in a group practice. The average working time was 39 hours per week, and an average of 45 patients were seen in the office daily. Doctors reported making an average of nine patient-related phone calls per day, and five home visits per week. The average list size was 1,866 patients. Participation in out of hours service for an average of 15 hours per week (on-call service included) was reported by 123 (72.1%) respondents; 79 (46.5%) practised an appointment system; 118 (68.8%) claimed that their patients had to wait more than a week for an appointment with a psychiatrist. Management decisions Twenty-six (20.2%) family physicians decided to refer their patient to a psychiatrist after the first contact, yet the majority started their own therapy (Table 1).A drug therapy was prescribed by 117 (90.6%) family physicians. A wide variety of therapeutic approaches were used. Thirty (25.9%) physicians prescribed one of the following combinations: 19 (16.4%) prescribed antidepressants and anxiolytics, five (4.3%) a combination of antidepressants and hypnotics, and six (5.2%) a combination of anxiolytics and hypnotics, while 87 (74.1%) gave an antidepressant as a single prescription. Only 12 (9.4%) of the participating physicians did not prescribe any medication at all. All family physicians gave advice to their patients; they most commonly encouraged them to re-establish normal social contacts, and increase leisure-time activity to involve more family visits and country walks. The majority of family physicians (114; 88.4%) scheduled a follow-up visit in two weeks’ time on average, at the earliest after three days, and at the latest after two months; the rest of them advised the patient to attend when feeling the necessity to come. A total of 118 (91.5%) participating family physicians seemed to have recognised the nature of the patient’s Table 1. Drugs prescribed for the depressed woman from the case vignette. As a quarter of the doctors prescribed more than one drug N is greater than 129. Tabela 1. Zdravila, ki so jih zdravniki predpisali depresivni bolnici, predstavljeni v vinjeti. ^etrtina zdravnikov je predpisala ve~ zdravil, zato je N ve~ji od 129. Drugs prescribed/ Predpisana zdravila Name (n) / Ime N Antidepressants / Antidepresivi fluoxetine (42), sertaline (8), fluvoxamine (1), tianeptine (4), moclobemide (1), maprotiline (6), amitriptyline (1), doxepin (1), trazodone (1) 65 Anxyolitics / Anksiolitiki alprazolam (44), bromazepam (17), medazepam (3), diazepam (2), lorazepam (2), prazepam (1), oxazepam (1) 70 Hypnotics / Hipnotiki zoldipem (14), flurazepam (3), nitrazepam (1), 18 Others / Drugi sulpiride (2), perazine (1), St. John's wort (1), tramadol (2), diclofenac (1), meloxicam (1), etidronate (1), Ca-C 500 (1), heparin gel (1) 10 Car J., Kersnik J., [vab I., Rotar-Pavli~ D. Detection and management of depression in Slovene family practice ... 93 mental problem. The right decision was made in 79 (61.2%) of the cases. Family physicians’ characteristics which correlate with their decision-making The following correlations were found: ? Family physicians working full time prescribed antidepressants more often than family physicians working on a part-time basis (p=0.01), and were more likely to make a correct diagnosis (p=0.02). ? Family physicians working more out of hours favoured antidepressant treatment (p=0.03). ? Family physicians with patient lists exceeding 1,500 persons prescribed a drug therapy more often than family physicians with less than 1,500 persons on the list (p=0.03). Family physicians with patient lists exceeding 1,500 persons were also less likely to take inappropriate decisions concerning depression management (p=0.05). ? Family physicians in towns with more than 10,000 inhabitants (p=0.04) take inappropriate measures less often ? Family physicians who prescribed drug treatment more frequently were on average six years younger than those who did not prescribe it (p= 0.03). ? Family physicians who did not prescribe drugs recommended a follow-up visit on average four days earlier than those who did prescribe a drug therapy (p=0.09). Discussion Data on the process of outpatient care are difficult to collect from everyday practice. This is especially true for psychosocial problems, such as depression. Decision-making processes are almost impossible to track down from medical records, and direct observations by videotaping or use of simulated patients have become a gold standard for audit. However, these methods are time-consuming, expensive and cannot be used on a large scale. In nationwide studies case vignettes are the method of choice for a limited insight into the decision-making and for quality assessment (21). Case vignettes offer standardised “patients” for whom the diagnosis and the treatment strategies are known. The method has proven equally effective as that of case simulation (21, 22) and the approach has been applied to research of depression in general practice (15, 23). Even though the vignette scenario may not reflect an everyday situation encountered by the participating physicians in the primary care setting, the observation of Rethans and Saebu that performance in real practice is consistent with the written case scenarios (24), as well as the results of a comparison of videotaped consultations and written scenarios by Braspenning and Sergeant (25), have reassured us that our results are indeed valid. Nevertheless, the interpretation of the data must be undertaken with caution, since the actual situation might be even worse (e.g. the time pressure factor is excluded). The main strength of the study is its high response rate and the representativeness of the sample.To our knowledge, this is also the first study using a case vignettes scenario for assessing primary care physicians’ performance in mental health in Slovenia, and is one of a very few of that type (25). In our study the recognition rates for mental health problems (91.5%) and recognition rates for depression (61.2%) in general practice were relatively high compared to the findings of Howe, who found that only 44% of the depressed were diagnosed for depression in general practice (13), or compared to the results of Kessler and co-workers who found only 36% of cases detected (14). Although the physicians were not informed about the kind of patients/diseases involved in the study when invited to participate, the result might suggest a bias in the methodology, since the physicians were aware of the simulated situation. It is well recognised that the spectrum of depression in primary care may be different from that seen in specialist psychiatry (12), and our case vignette has tried to simulate this difference (14). Nevertheless, the high rates of inappropriate prescribing of anxiolytic drugs as a single therapy might reflect the fact that the patient was recognised as having a mild depression, in which case the relief of symptoms is not so urgent (26). It can be assumed that the intenttion to treat was based on the severity of the depression evaluated by the physician, as found by (27) Dorwick and Buchan. One fifth of the physicians decided to refer the patient to the psychiatrist, which is not in line with the recommendations that primary care patients with mild depression should be treated with antidepressants (28-30). Follow-up instituted in our study by the participating physicians can help them adjust treatment regimes to the assessed severity of the depression, which allows us to believe that at some point in future antidepressants might be prescribed or patient referred 94 Zdrav Var 2006; 45 to the psychiatrist (27, 28, 31). A series of follow-up visits indicates a continuing interest in the patient which has a therapeutic value in its own right. Outcomes can be improved by using some of the psychological strategies of family physicians which have proven beneficial in the treatment of depression, either as a single method or in combination with antidepressants (8). Another important finding of our study is the shift in the prescribing habits of family physicians from classic tricyclic antidepressants to new SSRI antidepressants, providing valuable information about early adoption of new therapeutic strategies. This offers a good opportunity for planning changes in depression management patterns used by family physicians. Nearly 90% of the prescribed antidepressants were from the group of new-generation antidepressant drugs, which are associated with fewer side effects, better tolerability and are less likely to be lethal. It seems that the knowledge of the therapeutic possibilities of the new drugs is very high and that it is closer to the American (32) than to the British prescribing patterns (33). It is difficult to explain why family physicians in towns reported fewer inappropriate measures, and more detailed research is needed to clarify this finding. Family physicians in urban settings are more often organised in groups, which may influence their decision making. Another explanation may be that doctors practising in rural areas know the families better, and place more emphasis on non-drug therapies, such as the provision of psychological support. It is difficult to explain why younger family physicians were more likely to prescribe drug treatment. We can hypothesise that older doctors trust more the above mentioned non-drug therapies. The participating family physicians were relatively good at diagnosing depression in the case vignette. However, the evidence from routine statistical data suggests that depression is underestimated and undertreated in Slovenia. We believe that this is an important area for quality improvement. A causal relationship cannot be proved, yet we believe that these results are important to physicians who seek to improve their decision-making, and wish to promote self-evaluation and decrease the rate of non-optimal treatment decisions. For the same reason, the results provide valuable information to physicians’ organisations and insurance companies seeking to offer further professional advice to physicians. Clinical practice guidelines on the management of depression have to be formulated, but these must be accompanied by effective strategies for implementation. Acknowledgements The study was supported through a research grant from the Slovene Government grant No. References 1. Burvill PW. Recent progress in the epidemiology of major depression. Epidemiol Rev 1995; 17: 21-31. 2. Macdonald AJD. ABC of mental health: Mental health in old age. BMJ 1997; 315: 413-7. 3. Maru{i~ A. Depresija - spregledana in zanemarjena bolezen. In: Dernov{ek MZ, Tav~ar R. Prepoznajmo in premagajmo depresijo: priro~nik za osebe z depresijo in njihove svojce. Ljubljana: In{titut za varovanje zdravja Republike Slovenije, 2005; 4. 4. Samarin-Lovri~ S, Maru{i~ A, Kenda MF. Depresija po akutnem sr~nem infarktu pri starostnikih. Slov Kardiol 2005; 2(1): 20-3. 5. Kersnik J. Prepoznavanje znakov depresije in anksioznosti. In: Kersnik J, editor. Kroni~na bole~ina, sladkorna bolezen, depresija in preventivni program. Zbornik predavanj 4. Fajdigovi dnevi; 2002 okt 11-12; Kranjska Gora. Ljubljana: Zdru‘enje zdravnikov dru‘inske medicine SZD, 2003; 78-84. 6. van Weel-Baumgarten EM, van den Bosch WJHM, van den Hoogen HJM, Zitman FG. Ten year follow-up of depression after diagnosis in general practice. Br J Gen Pract 1998; 48: 1643-6. 7. Geddes J. Depressive disorders. In: Clinical evidence. A compendium of the best available evidence for effective health care. London : BMJ Publishing group 1999: 354-65. 8. Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000; 320: 26-30. 9. Hjortdahl P. Continuity of care: General practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Pract 1992; 9: 3-8. 10. van Weel-Baumgarten EM, van den Bosch WJHM, van den Hoogen HJM, Zitman FG. The validity of the diagnosis of depression in general practice: is using criteria for diagnosis as a routine the answer? Br J Gen Pract 2000; 50: 284-7. 11. Vaeroy H, Merskey H. The prevalence of current major depression and dysthymia in a Norwegian general practice. Acta Psychiatr Scand 1997; 95(4): 324-8. 12. van Weel-Baumgarten EM, van den Bosch WJHM, Hekster YA, van den Hoogen HJM, Zitman FG. Treatment of depression related to recurrence: 10-year follow-up in general practice. J Clin Pharm Therapeutics 2000; 25: 61-6. 13. Howe A. Detecting psychological distress: Can general practitioners improve their own performance? Br J Gen Pract 1996; 46: 407-10. 14. Kessler D, Lloyd K, Lewis G, Pereira Gray D. Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ 1999; 318: 436-40. 15. Orrell M, Collins E, Shergil S, Katona C. Management of depresion in the elderly by General Practitioners: I. Use of antidepresants. 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Changing patterns of antidepressant use and costs in a health maintenance organisation. Pharmacoeconomics 1997; 11: 274-86. Appendix A 79-year-old unmarried, retired teacher visits you in your office. She lives alone in her own house, and raises a few hens. Ten years ago she underwent a radical leftside mastectomy for cancer. All follow-up examinations were normal and showed no progression of the disease. She suffers from mild osteoarthritis of the knees. Eight months ago she fell and is now afraid of leaving her house without assistance. The local Caritas association, where she had been very actively involved until this event, helps her with daily activities. She complains about fear, depressed mood and lack of joy because of constant worries. At her last visit, one month ago, she complained of sleeplessness, and was prescribed 5mg diazepam pills to be taken before sleep. She took the drugs only once, because of side-effects of nausea. She asks for some pills for the nerves. Physical examination revealed no abnormalities. Apart from diclofenac pills taken when the pain in her knees gets worse, she takes no other medication. 96 Zdrav Var 2006; 45: 96-106 NA^RTOVANJE [TEVILA ZDRAVNIKOV IN ZOBOZDRAVNIKOV V ZDRAVSTVU - METODE, UPORABNOST, OMEJITVE IN ODVISNOSTI PHYSICIAN AND DENTIST WORKFORCE PLANNING METHODS, APPLICABILITY, LIMITATIONS AND DEPENDENCE Irena Gr mek-Ko{nik1, Tit Albreht2 Prispelo: 30. 3. 2005 - Sprejeto: 12. 1. 2006 Pregledni znanstveni ~lanek UDK 614.2 Izvle~ek Izhodi{~a: Na~rtovanje {tevila zdravnikov in zobozdravnikov je ena najte‘jih oziroma najbolj zahtevnih nalog na~r tovanja sistema zdravstvenega varstva. Najpogostej{e ovire za u~inkovito na~rtovanje zdravstvenih delavcev so: pomanjkanje znanja o povpra{evanju po zdravnikih, nepreverjenimi demografski podatki o zdravnikih, pomanjkanje podatkov o nezapolnjenih delovnih mestih, zastarelost podatkov o {tevilu poklicev, slaba dostopnost zahtevanih podatkov. Metode: S pomo~jo podatkov o {tevilo aktivnih zdravnikov in zobozdravnikov na podlagi zdravstvenostatisti~nih letopisov, ki jih izdaja In{titut za varovanje zdravja Republike Slovenije, za leto 1980, 1990 in 2002 in razpisanih mest specializacij v prvem nacionalnem razpisu za leto 2003, smo poskusili napovedati gibanja o potrebah zdravnikov v prihodnjih letih ter ovrednotiti primernost dosedanjega na~rtovanja zdravnikov. Rezultati: [tevilo aktivnih zdravnikov in zobozdravnikov skupaj se je od leta 1980 na 1990 pove~alo za 1172 (32,3%) oz. je bil povpre~ni letni prirastek 3,2%. Od leta 1990 do leta 2002 se je zdravni{ki stan okrepil le za 655 (12%) novih zdravnikov in zobozdravnikov oz. je bil povpre~ni letni prirastek le 1%. [tevilo diplomantov medicinske fakultete je od leta 1986 do 2002 zelo nihalo. Zaklju~ki: Razli~ni izra~uni ka‘ejo, da v obstoje~i mre‘i ob sedanjih provizori~nih normativih primanjkuje nekaj sto zdravnikov. Ocenili smo, da se bo vsaj nekaj let {e nadaljeval trend zmanj{evanja oskrbljenosti z zdravniki. [tevilo aktivnih zdravnikov bodo v glavnem zagotavljali diplomanti Medicinske fakultete v Ljubljani in po nekaj letih tudi Medicinske fakultete v Mariboru, okrog 4-8% tudi z zaposlovanjem zdravnikov iz tujine.Trenutno stanje na~r tovanja kadrov v zdravstvu je {e dale~ od optimalnega. Klju~ne besede: zdravstveno varstvo, na~rtovanje, zdravniki, zobozdravniki, diplomanti, specializanti, zaposlovanje, primerjalno raziskovanje Review article UDC 614.2 Abstract Background: Doctor and dentist workforce planning is one of the most complex tasks in the health care system planning. Efficient planning of health professionals is most commonly hindered by lack of data regarding the demand for physicians and vacancies, by verified demographic data on physicians, by outdated information on the available number of professionals, and by difficulty to access the needed. Methods: Using statistics on active physicians and dentists provided by health statistical yearbooks for 1980, 1990 and 2003, issued by the Institute of Public Health of the Republic of Slovenia, as well as data on specialist training posts from the first national tender in 2003 to predict need for physicians over the next years, and to evaluate the adequacy of previous predictions. Results: Between 1980 and 1990, the total number of active physicians and dentists increased by 1172 (32.3%), the average annual increase being 3.2%. During the period 1990 - 2003, this number increased by 655 (12%), which 1Zavod za zdravstveno varstvo Kranj, Gosposvetska 12, 4000 Kranj 2In{titut za varovanje zdravja Republike Slovenije, Trubarjeva 2, 1000 Ljubljana Kontaktni naslov: e-po{ta: irena.grmek-kosnik@zzv-kr.si Grmek-Ko{nik I., Albreht T. Na~rtovanje {tevila zdravnikov in zobozdravnikov v zdravstvu - metode, uporabnost, ... 97 brought the average annual increase down to less than 1%. It needs to be stressed that the annual number of medical graduates in Slovenia varied considerably during the period 1986 - 2003. Conclusions: Several reliable calculations (using the current provisional workforce standards) showed that there is a net lack of a few hundred physicians in the public network. The trend of physician deficit is estimated to continue for at least several years. The demand will predominantly be met by employing medical and dental graduates from the Faculty of Medicine , University of Ljubljana, in a few years followed by the graduates from the newly opened Faculty of Medicine in Maribor. An estimated 4% - 8% of the total workforce will need to be imported from abroad. Current trained specialist workforce planning is still far from optimal. graduates, residents, employment, comparative research Key words: health care, planning, physicians, dentists, Uvod Osnovna nosilca zdravstvene dejavnosti sta zdravnik in zobozdravnik. Dolo~itev potrebnega {tevila zdravnikov in zobozdravnikov je ena najte‘jih oziroma najbolj zahtevnih nalog na~rtovanja sistema zdravstvenega varstva, ki ga opredeljujejo predvsem ekonomska mo~ dr‘ave, oblike delovanja in izvajanja zdravstvene dejavnosti ter njena organiziranost. Vzrok za te‘ave pri na~rtovanju je predvsem v delno skupnih in delno nasprotujo~ih si interesih vseh vpletenih. Eno od osnovnih nasprotij je razmerje med povpra{evanjem po zdravstvenih storitvah in njihovo ponudbo. V sistemih, kjer so tr‘ni mehanizmi bolj vpeti v sistem zdravstvenega varstva, se je razvila velika ponudba storitev, ki je zahtevala tudi bistveno ve~je {tevilo zdravni{kega osebja. Tr‘no usmerjeni zdravstveni sistemi, ki se na to razmerje najve~krat sklicujejo, imajo v glavnem dva cilja - eden je v optimizaciji stro{kov, drugi pa v ponudbi ~imve~jega {tevila raznovrstnih storitev (slednje seveda niso nujno povezane z zadovoljevanjem dejanskih zdravstvenih potreb prebivalstva). Ta dva cilja sta si seveda v mnogo~em v nasprotju. Trendi v stro{kih za zdravstveno varstvo v najdra‘jem sistemu, to je v ZDA, ka‘ejo {e vedno nadaljevano rast stro{kov. Ta je sicer po~asnej{a kot v 80. in 90. letih, vendar skupni izdatki dosegajo ‘e ve~ kot 14% BDP. Vpliv {tevila zdravnikov in zaposlenega kadra na te izdatke je seveda klju~nega pomena, saj po podatkih OECD3 njene ~lanice za stro{ke dela porabijo med 70 in 75% vseh sredstev za zdravstvo. Pri tem je zanimivo, da so se ocene potreb po zdravnikih v ZDA v zadnjih desetih letih bistveno spremenile. Medtem ko je v ~asu Clintonove reforme (1992-1994) {e veljalo, da je zdravnikov preve~ pri {tevilu 250 zdravnikov na 100.000 prebivalcev4, danes ponovno govorijo o pomanjkanju zdravnikov. Tudi v evropskih dr‘avah smo pri~a podobnim procesom, saj se celo dr‘ave z nekdaj velikimi prese‘ki zdravnikov (npr. [panija in Nem~ija) danes sre~ujejo z relativno uravnote‘enima ponudbo in povpra{evanjem. Seveda pa je uveljavitev tr‘nih mehanizmov v zdravstvenem varstvu lahko le delna. Vzroka sta predvsem dva. Bolniki kot uporabniki zdravstvenih storitev so samo delno strokovno informirani in ta informiranost ne more prese~i neke njim dosegljive meje (t.i. informacijska asimetrija); drugi vzrok pa je v tem, da mora socialna dr‘ava skrbeti za bla‘itve socialnih razlik, ki ne smejo vplivati na dostopnost osnovnih in najnujnej{ih storitev zdravstvenega varstva. [e ve~, sistem zdravstvenega varstva naj bi bla‘il in manj{al razlike, do katerih prihaja zaradi razli~nega zdravstvenega stanja. Na~rtovanje zdravstvenih delavcev je zahtevna naloga, ki jo lahko ustrezno izpeljemo s pomo~jo: 1. jasno postavljenih meril - demografskih, epidemiolo{kih in storilnostnih 2. u~inkovitih virov informacij z ra~unalni{ko podprtimi zbirkami podatkov in; 3. z opredeljenimi normativi in standardi ter ustreznimi merili za vrednotenje storilnosti in kakovosti storitev. Najpogostej{e ovire pri kvantitativnih metodah so: pomanjkanje znanja o povpra{evanju po zdravnikih, demografski podatki o zdravnikih niso preverjeni, ni podatkov o nezapolnjenih delovnih mestih, kot so porodni{ke odsotnosti in odsotnosti zaradi specializacij, ~asovno odmaknjeni podatki o {tevilu zaposlenih v posameznem poklicu (potrebno je 18 do 20 mesecev za publiciranje), v~asih je te‘ko priti do zahtevanih podatkov. Potrebno je vzpostaviti jasna merila na ravni dr‘ave in posamezne stroke, iz tega pa potem izhajajo usklajeni izra~uni in podatki. Podatke je potrebno preverjati, nabor podatkov in na~in zbiranja pa mora biti natan~no opredeljen (1). Pri tem je zelo pomembno tudi povezovanje med razli~nimi zbirkami podatkov, ki sicer slu‘ijo razli~nim namenom - IVZ, Zdravni{ka zbornica Slovenije in Zavod za zdravstveno zavarovanje Slovenije. 3OECD Database 4Iglehart 98 Zdrav Var 2006; 45 [tevilo zdravnikov in njegovo dolo~anje sta bili pomembni vpra{anji tudi ‘e v za~etku prej{njega stoletja, ko so primerjave med ZDA in evropskimi dr‘avami pokazale 25 do 50% ve~je relativno {tevilo zdravnikov v ZDA (ob ‘e tedaj prisotni regionalno neenakomerni razporejenosti). Razmah zdravstvene dejavnosti je bil povezan tudi v Evropi z izrednim pove~anjem {tevila zdravnikov, {e posebej v 60. in v za~etku 70. let. V Sloveniji se je {tevilo zdravnikov v obdobju med 1965 in 1984 pove~alo s 1688 na 3596 oziroma za 113% (2, 3). V Sloveniji je bilo leta 1965 102 zdravnika na 100.000 prebivalcev, v ZDA pa 140 zdravnikov na 100.000 prebivalcev, leta 1984 pa so bile te {tevilke 186 za Slovenijo in 220 za ZDA. Gospodarska kriza druge polovice 70. let in za~etka 80. let je privedla do streznitve. V zadnjih letih so krizo financiranja sistemov zdravstvenega varstva spremljale tudi obse‘nej{e {tudije o potrebnem {tevilu zdravnikov in zobozdravnikov. Omenjena poklica sta namre~ klju~na pri odlo~anju o storitvah in s tem o stro{kih v sistemu zdravstvenega varstva. Njihovo izobra‘evanje stane veliko denarja. Kot ugotavlja Fry, bo zdravnik od za~etka {tudija pa do upokojitve povzro~il National Health Service (NHS) pribli‘no 3 milijone angle{kih funtov stro{kov, poleg tega pa bo s svojim strokovnim delom (zdravila, predpisana na recept, in napotitve bolnikov na specialisti~no in bolni{ni~no zdravljenje) spro‘il {e dodatne stro{ke, tako, da bo kon~ni znesek ‘e 12 milijonov angle{kih funtov (6). Vsekakor pa je pove~anje stro{kov za zdravstveno varstvo rezultanta {tevilnih dejavnikov, kot so: napredek medicine, staranje prebivalstva in rast ‘ivljenjskega standarda. Slednji povzro~a ve~ povpra{evanja zaradi bolj storitvene usmeritve tako bolnikov kot zdravnikov, poleg tega pa ve~jo razvitost spremljajo tudi druga~ne epidemiolo{ke zna~ilnosti (ve~ kroni~nih bolezni in bolezni zaradi staranja). Klju~na determinanta, ki ‘e vnaprej dolo~a {tevilo zdravnikov v prihodnje, je {tevilo {tudentov medicine in stomatologije oziroma {tevilo diplomantov, saj velja, da vpisani {tudent tudi postane zdravnik oz. zobozdravnik. Osip pri tem {tudiju je namre~ zelo majhen in navadno ne presega 5% (7). Tudi po dokon~anju {tudija in ob strokovnem usposabljanju bo zdravnik ostal zvest svojemu poklicu, saj je dejanske fluktuacije malo. Zmogljivosti medicinskih fakultet so na primer v ZDA zelo velike, saj je poklic zdravnika in zobozdravnika {e vedno finan~no izredno privla~en. Te zmogljivosti so ve~inoma povezane z zmogljivostmi za podiplomsko usposabljanje, predvsem za specializacije. Ameri{ki model je odsev tr‘nih mehanizmov, je pa pri svojem delovanju mo~no odvisen od dela mlaj{ih zdravnikov (6). V socializiranih sistemih izobra‘evanja, kakr{ni so evropski, stanje zrcali druga~ne oblike povpra{evanja. Tako imata [panija ali Nem~ija enega diplomanta na 4.000, medtem ko je Povpre~no v Zahodni Evropi en diplomant medicine na 7.500 prebivalcev. To razmerje je v Sloveniji pribli‘no eden na 13.000 prebivalcev. Vendar pa hitre spremembe {tevila zdravnikov (tudi ob izkazanih in dokazanih potrebah) s pove~anjem vpisa na fakulteto niso mo‘ne: prvi~ zato, ker hitre spremembe glede na trajanje {tudija tako ali tako niso mo‘ne, saj so u~inki spremenjenega {tevila {tudentov in s tem {tevila diplomantov vidni {ele 7 do 10 let po vpeljavi sprememb; drugi~ pa zato, ker je financiranje fakultet povezano s {tevilom vpisanih {tudentov. V ZDA je v zadnjih letih posebej zanimiva zahteva, da mora na~rtovanje ponudbe zdravnikov ostati jasna dejavnost javnega sektorja, saj je le na ta na~in mo‘no zagotoviti enakomerno preskrbljenost prebivalstva (8). Po drugi strani pa v ve~ini evropskih dr‘av in v Kanadi dolo~ajo {tevilo zdravnikov s pomo~jo dr‘avnih odlo~itev (9). Po podatkih za leto 2002/2003 je v bilo v Evropski uniji (EU) skupaj 1,37 milijona zdravnikov. (10) Ve~inoma se razviti zdravstveni sistemi {e vedno zatekajo k na~rtovanju na podlagi demografskih podatkov o prebivalstvu in populaciji zdravnikov in zobozdravnikov, v bistveno manj{i meri pa na podlagi storilnostnih meril. Kot je pokazal tudi Reinhardt (11), je sicer mo‘no razviti kompleksne modele za vklju~evanje zelo razli~nih parametrov, ki pa se na koncu omejujejo po eni strani z razpolo‘ljivostjo in dostopnostjo teh podatkov, po drugi strani pa z njihovo kakovostjo. Namen in cilji Namen {tudije je bil pregledno prikazati klju~ne elemente, ki vplivajo na na~in na~rtovanja zdravni{ke in zobozdravni{ke populacije, poiskati zakonske osnove za planiranje kadrov v zdravstveni dejavnosti, strokovne osnove, iz katerih naj bi planiranje izhajalo, ter se seznaniti z metodami planiranja zdravstvene dejavnosti. Ob tem smo poiskali podatke za oceno demografskih gibanj zdravni{ke populacije in analizo demografska gibanja med zdravniki in zobozdravniki. Na ta na~in naj bi pomagali presoditi tudi umestnost {tevila sedanjega vpisa na Medicinsko fakulteto v Ljubljani in Mariboru ter potrebe po enostavnem nadome{~anju teh dveh poklicev zaradi demografskih zna~ilnosti obeh populacij. Nismo pa nameravali upo{tevati {e vseh drugih elementov, ki seveda sodijo Grmek-Ko{nik I., Albreht T. Na~rtovanje {tevila zdravnikov in zobozdravnikov v zdravstvu - metode, uporabnost, ... 99 v integralne izra~une potreb po zdravnikih, kot so epidemiolo{ke zna~ilnosti prebivalstva, njegova zbolevnost in umrljivost ter pri~akovanja prebivalcev glede dostopnosti in glede obsega storitev zdravstvenega varstva in storilnostni dejavniki za vrednotenje dela pri zdravnikih in zobozdravnikih. Material in metode Za {tudijo smo zbrali vhodne podatke o {tevilu aktivnih zdravnikov in zobozdravnikov ter {tevilu diplomantov medicine in stomatologije na podlagi zdravstvenostatisti~nih letopisov, ki jih izdaja In{titut za varovanje zdravja Republike Slovenije (IVZ RS), za leto 1980, 1990 in 2002 (Tabela 1). Pri analizi gibanja {tevila zdravnikov v zadnjih desetih letih smo uporabili statisti~ne podatke, ki jih je zbiral In{titut za varovanje zdravja, pred tem pa Univerzitetni zavod za zdravstveno in socialno varstvo (UZZSV). IVZ je od leta 1993 zasnoval evidence na podlagi podatkov iz Baze podatkov izvajalcev zdravstvene dejavnosti, pred tem pa UZZSV na podlagi Evidence zdravstvenih delavcev. Obe bazi sta temeljni nacionalni zbirki za zdravstvene poklice s standardiziranim naborom podatkov in navzkri‘no preverljivimi in uskladljivimi osebnimi podatki. Slovenske izku{nje pri planiranju kadrov v zdravstvu Sedanje planiranje kadra v zdravstvu temelji {e vedno na metodi, ki opredeljuje potrebe po zdravniku v obliki koli~nika med {tevilom zdravnikov in {tevilom prebivalcev. Osnova pri tem je uporaba nacionalne zdravstvene statistike (11). Zahteve za planiranje opredeljuje Nacionani program zdravstvenega varstva Republike Slovenije - Zdravje za vse do leta 2004. Program predvideva, da se bo prebivalstvo Slovenije v naslednjih letih rahlo zmanj{evalo. Do leta 2020 naj bi se zmanj{alo za pribli‘no 5%. Razmerje med upokojenci in delovno aktivnimi prebivalci v obdobju od leta 1995 - 2005 se bo zmanj{alo na 0,5, v letu 2010 pa se bo pri~elo to razmerje pove~evati in bo do leta 2020 doseglo raven 0,6. Zadnje projekcije, ki jih je pripravil Eurostat (12), sicer nakazujejo mo‘nost prehodnega rahlega pove~anja {tevila prebivalcev, vendar je dejstvo, da se je {tevilo stalnega prebivalstva v zadnjih 8 letih v Sloveniji neprestano zmanj{evalo. Primerjave glavnih kazalcev zdravstvenega stanja in financiranja Slovenije v primerjavi z EU in s {tirimi razvitimi dr‘avami Evropske unije (Avstrijo, Nem~ijo, Nizozemsko in Veliko Britanijo) potrjujejo, da na podro~jih osnovne zdravstvene dejavnosti, bolni{ni~ne dejavnosti in zdravil na recept Slovenija dosega podobno raven kot dr‘ave ~lanice EU (glej tabelo 3). Te dr‘ave so bile izbrane, ker imajo tri podobne sisteme zdravstvenega zavarovanja, Velika Britanija pa kot predstavnica dr‘avnega sistema zdravstvenega varstva. Slabost sedanjega planiranja je v tem, da metodologija ni dovolj strukturirana. Upo{teva le zdravni{ko demografijo in splo{no populacijo na drugi strani. V obstoje~o metodologijo bi bilo potrebno vklju~iti funkcionalne parametre, kot so ~as, potreben za bolnika, za posamezno diagnozo, za postopek, za specialnost in razli~ne kombinacije, poleg tega pa {e druge parametre dostopnosti. Sistem financiranja dejavnosti naj bi nadalje stimuliral bolj produktivno naravnano delo. Od leta 1992 dalje je bila sprejeta zakonodaja, ki ureja razli~na podro~ja zdravstvenega varstva: Zakon o zdravstvenem varstvu in zdravstvenem zavarovanju, ki med drugim ureja sistem zdravstvenega varstva ter nosilce dru‘bene skrbi za zdravje (13). Republika Slovenija uresni~uje svoje naloge na podro~ju zdravstvenega varstva tudi s tem, da na~rtuje zdravstveno varstvo in dolo~a strategijo razvoja zdravstvenega varstva. Za uresni~evanje te in {e drugih nalog (4.~len) deluje pri Vladi Republike Slovenije Svet za zdravje. Predlagatelji predpisov in razvojnih planov zdravstvenega varstva so dol‘ni obravnavati predloge, pobude in mnenja Sveta za zdravje ter do njih zavzeti stali{~a, z njimi pa seznaniti Dr‘avni zbor Republike Slovenije. Zakon o zdravni{ki slu‘bi opredeljuje zdravnika kot temeljnega odgovornega nosilca opravljanja zdravstvene dejavnosti (14). Zdravni{ka slu‘ba se opravlja na zdravni{kih delovnih mestih v okviru mre‘e javne zdravstvene slu‘be in zunaj nje. Zdravni{ka delovna mesta v okviru mre‘e javne zdravstvene slu‘be se razporedijo po obmo~jih in po specialisti~nih podro~jih tako, da se zagotovi prebivalcem ~im bolj enaka dostopnost do kakovostnih zdravstvenih storitev. Zdravni{ka delovna mesta se v mre‘i javne zdravstvene slu‘be prerazporedijo po strokovnih podro~jih: v javnih zavodih, pri drugih pravnih osebah s koncesijo in pri zasebnikih s koncesijo. Razpored zdravni{kih delovnih mest v mre‘i javne zdravstvene slu‘be dolo~i minister, pristojen za zdravje. Zdravni{ka zbornica Slovenije (ZZS) v zvezi z razporedom zdravni{kih delovnih mest v mre‘i javne zdravstvene slu‘be spremlja zasedenost zdravni{kih delovnih mest, nezaposlenim zdravnikom posreduje informacije o prostih zdravni{kih delovnih mestih, delodajalcem pa informacije o nezaposlenih zdravnikih, 100 Zdrav Var 2006; 45 daje mnenje o podeljevanju koncesij zasebnikom, v skladu s potrebami in starostno strukturo zdravnikov posameznih strok na~rtuje in odobrava specializacije. Tako je ZZS klju~no soudele‘ena pri na~rtovanju zdravni{kih delovnih mest, predvsem ob opredelitvi razvojnih vpra{anj, kot so mre‘a specializantskih delovnih mest. Dejansko stanje. V Sloveniji sorazmerno dobra razpr{enost zdravstvene slu‘be po terenu omogo~a lahko fizi~no dostopnost storitev osnovnega zdravstvenega varstva kot tudi ambulantne specialisti~ne in bolni{ni~ne dejavnosti. Seveda dober vtis poslab{ujejo problemi pri zagotavljanju ustreznega obremenjevanja kadrov in celo pokrivanje obstoje~ih delovnih mest v nekaterih predelih Slovenije. Pri pregledu zdravstveno statisti~nih podatkov, kot tudi v stali{~nih javnomnenjskih raziskav, lahko ugotovimo, da se povpra{evanje po zdravstvenih storitvah v Sloveniji pove~uje. K temu je poleg lahke dostopnosti izvajalcev zdravstvene dejavnosti prispeval tudi na~in financiranja zdravstvene dejavnosti, kakr{en je v veljavi od leta 1993. Za zavarovalni{ke sisteme, kakr{nega smo uvedli tudi v Sloveniji z Zakonom o zdravstvenem varstvu in zdravstvenem zavarovanju, je namre~ zna~ilno ve~je povpra{evanje po zdravstvenih storitvah kot v dr‘avah s sistemom nacionalnega zdravstvenega varstva (15). Tako stanje zrcali povpra{evanje po kurativnih storitvah. Preventivni pregledi pri osebnem zdravniku ka‘ejo pri odrasli populaciji {e nadalje trend zni‘evanja. Za preventivni obisk se odlo~i komaj vsak deseti (16). V zunajbolni{ni~ni dejavnosti smo leta 2000 ugotavljali povpre~no 7,4 obiska na prebivalca, kar je bilo skoraj 25% ve~ kot leta 1990. Ta {tevilka vklju~uje vse obiske na vseh ravneh dejavnosti. Od tega jih pribli‘no polovica odpade na primarno raven, pribli‘no ena tretjina pa na specialisti~no. V zadnjih desetih letih se je {tevilo obiskov nenehoma pove~evalo. Stanje pri otrocih je nekoliko bolj{e glede preventivnih pregledov. Upo{tevati je seveda potrebno, da je pri tej populaciji v veljavi aktiven pristop z vabilom in rednimi preventivnimi pregledi. Po drugi strani pa se je {tevilo kurativnih pregledov otrok od 1. do 6. leta starosti v zadnjem desetletju pove~alo kar za 14% (17). Pri {olajo~ih je v istem ~asu pri{lo do upada {tevila preventivnih pregledov, in sicer kar za ~etrtino. Pri odraslih prebivalcih ugotavljamo postopno umirjanje rasti {tevila pregledov v dejavnosti splo{ne medicine in ustalitev na pribli‘no 3,75 pregleda na prebivalca. Med vzroki za tako veliko {tevilo obiskov velja omeniti predvsem dobro dostopnost storitev primarnega zdravstvenega varstva, ve~jo zahtevnost bolnikov, predvsem za specialisti~ne storitve, postopno ve~je zavedanje o pomenu lastne skrbi za zdravje, kot tudi ukinitev kakr{nih koli dopla~il v osnovni zdravstveni dejavnosti leta 1993. Seveda ima tako veliko {tevilo obiskov pomembne negativne u~inke. Najbolj o~itna posledica je kraj{anje ~asa na posamezen stik med zdravnikom in bolnikom. Ena od posledic, ki jo ka‘e posebej poudariti, je hitro nara{~anje {tevila napotitev k specialistom po kurativnih obiskih pri zdravnikih splo{ne oziroma dru‘inske medicine (16). Do 90. let je bil dele‘ napotitev sorazmerno stabilen in se je gibal do 5%. Po hitri rasti v drugi polovici 90. let smo dosegli raven 15%. V istem ~asu se {tevilo neposrednih napotitev v bolni{nico ni zna~ilno pove~alo. Osnovna zdravstvena dejavnost se je v zadnjem desetletju kljub kadrovskim te‘avam v zdravstvu vseeno nekoliko okrepila, kar se ka‘e v zmanj{anju {tevila prebivalcev na zdravnika v posamezni dejavnosti. Tako je v dejavnosti zdravstvenega varstva otrok {tevilo otrok na zdravnika v dejavnosti v 90. letih upadlo za 10% in je leta 1999 zna{alo 906 otrok na zdravnika (17). @al so prisotne velike razlike po obmo~jih celo v razmerju do 1:2. Podoben je bil tudi razvoj na podro~ju zdravstvenega varstva {olskih otrok in mladine, kjer se je {tevilo otrok na zdravnika zmanj{alo od skoraj 2700 v za~etku 90. let na pribli‘no 2200 leta 1999. Na podro~ju splo{ne medicine se je pomembno izbolj{ala tako splo{na kadrovska zasedenost dejavnosti, saj se je {tevilo zdravnikov v zadnjem desetletju pove~alo za tretjino. Poleg tega se je pove~ala tudi strokovna usposobljenost zaradi intenzivnega izvajanja programa specializacije splo{ne oziroma dru‘inske medicine. Zanimivo je, da so se na podro~ju splo{ne medicine zmanj{ale razlike med obmo~ji (11). Uporaba zdravstvene slu‘be in primerjave z drugimi dr‘avami za zunajbolni{ni~no dejavnost po {tevilu obiskov Slovenijo uvr{~a na povpre~no raven med srednje- in vzhodnoevropskimi dr‘avami (povpre~je le-teh je 7,6). Primerjava z dr‘avami ~lanicami EU poka‘e, da je ve~ obiskov le v Belgiji (7,7) (18). To pomeni, da so se za Slovenijo uvrstile tako dr‘ave brez omejitev pri dostopu do specialisti~nih storitev, kot sta npr. Francija ali Nem~ija, kot tudi, in {e bolj izrazito, druge dr‘ave, ki imajo uveljavljen ‘vratarski sistem’ na ravni zdravnika splo{ne medicine oziroma dru‘inskega zdravnika. Pri vratarskem sistemu je za vse nadaljnje napotitve k specialistom potrebna odobritev s strani zdravnika splo{ne ali dru‘inske medicine. Slednje je pomembno zato, ker je ravno vratarski sistem v~asih tar~a kritik kot vzrok za veliko {tevilo obiskov. Sicer pa so v prej omenjeni anketi vratarski sistem bolniki v Sloveniji podprli. Podobno pa je pokazala tudi analiza istega vpra{anja s pomo~jo ciljnih skupin v letu 2001 (19). Bolni{ni~no dejavnost v zadnjem obdobju Grmek-Ko{nik I., Albreht T. Na~rtovanje {tevila zdravnikov in zobozdravnikov v zdravstvu - metode, uporabnost, ... 101 zaznamuje pove~evanje intenzivnosti dela, in sicer predvsem ve~ji obrat bolnikov. ^e pogledamo fizi~ne kazalce o delu bolni{nic, potem lahko vidimo postopno pove~evanje stopnje hospitalizacije (8% v desetih letih) do konca 90. let. Od tedaj dalje se ne pove~uje ve~ in je {e vedno ni‘ja kot v {tevilnih dr‘avah ~lanicah EU. Hkrati s tema dvema kazalcema se je skraj{alo tudi povpre~no trajanje hospitalizacije, in sicer od pribli‘no 12 dni leta 1990 na dobrih 9 v letu 1999. [e vedno pa je to trajanje dalj{e kot v primerljivih dr‘avah. Zanimivo je tudi gibanje stopnje hospitalizacije po spolu. Medtem ko sta bila spola na za~etku 90. let {e prakti~no izena~ena, se je v zadnjih letih ta kazalec mnogo izraziteje pove~al pri ‘enskah (11). V Sloveniji je bil globalni nadzor nad {tevilom zdravnikov in zobozdravnikov ‘e ve~ kot 40 let precej natan~en. Nadzor se je izvajal z vpisno politiko na Medicinsko fakulteto v Ljubljani, kar je tudi edini racionalni na~in za nadzorovanje {tevila zdravnikov. To je imelo za posledico precej zmerno pove~evanje {tevila zdravnikov, saj smo podvojitev {tevila iz leta 1965 dosegli {ele 1980. Ponudba zdravnikov v nekaterih intenzivnih podro~jih zdravstvene mre‘e ni bila zadostna in se je zato pokrivala z diplomanti drugih fakultet nekdanje Jugoslavije. Leta 1999 smo imeli 220 zdravnikov na 100.000 prebivalcev, kar je primerljivo s cilji racionalnih dr‘av, kot so Velika Britanija, Kanada, ZDA in Avstralija (20). V Evropi se {tevilne dr‘ave (Italija, Nem~ija, [panija, Avstrija), ki so podpirale velike zmogljivosti svojih medicinskih fakultet, danes soo~ajo s skorajda neobvladljivim problemom zaposlovanja zdravnikov. Taki trendi so na podro~ju javne porabe popolnoma nesprejemljivi. Zato so v vseh {tirih dr‘avah morali sprejeti bolj restriktivne ukrepe glede vpisne politike na medicinske fakultete. U~inek ve~jih povojnih generacij na demografske zna~ilnosti zdravnikov in zobozdravnikov je tak, da se zdravni{ka populacija v Sloveniji postopno stara. Povpre~na starost zdravnikov se je v obdobju 1986 do 1995 pove~ala od 42 na 43,7 leta, pri ~emer so ‘enske 7 let mlaj{e, saj je njihov dele‘ v mlaj{ih starostnih skupinah bistveno ve~ji in dosega 60%. Zobozdravniki se starajo {e intenzivneje, saj se je v obdobju 1986 do 1995 povpre~na starost pove~ala od 41,4 na 47,8 leta (21). V Sloveniji je bilo v 70. in 80. letih izdelanih ve~ analiz. Leta 1973 je Ivan Kastelic opozoril na nujnost na~rtnega prou~evanja gibanja {tevila zdravstvenih delavcev (22). Tedaj so ugotavljali pomanjkanje {tevila zdravnikov, posebno v osnovni zdravstveni slu‘bi. Skupno je na za~etku leta 1973 glede na minimalne kadrovske normative primanjkovalo 226 zdravnikov razli~nih specialnosti in 113 zobozdravnikov. Kar zadeva bolni{ni~ne dejavnosti so tedaj ugotavljali prese‘ek 186 zdravnikov, vendar pa jih je v specialisti~ni slu‘bi primanjkovalo kar 260. Tako je v zdravstvu v Sloveniji leta 1973 primanjkovalo skupaj kar 300 zdravnikov. Naslednja analiza, ki je ocenjevala mo‘nosti nara{~anja {tevila zdravstvenih delavcev za naslednje 5-letno obdobje, je bila pripravljena leta 1976, njen nosilec pa je bil prav tako Ivan Kastelic (23), Njen osnovni namen je bil pripraviti ocene pove~anja {tevila zdravstvenih delavcev za potrebe na~rtovanja. Iz podatkov o {tevilu zdravnikov in zobozdravnikov lahko vidimo, da se je {tevilo zdravnikov od leta 1980 do leta 1990 pove~alo za 1172 (32,3%) oz. je bil povpre~ni letni prirast 3,2%. Od leta 1990 do leta 2002 se je zdravni{ki stan okrepil le za 655 (12%) novih zdravnikov in zobozdravnikov oz. je bil povpre~ni letni prirast le 1%. Sredi 80. let prej{njega stoletja sta bili na Univerzitetnem zavodu zdravstveno in socialno varstvo (UZZSV) pripravljeni {e dve analizi. Nosilec prve je bila Bo‘ena Ravnikar, ki je prvi~ natan~neje primerjala {tevil~no rast zdravstvenih delavcev s sistemom izobra‘evanja za zdravstvene poklice na vseh ravneh (24). Predstavljena je bila podrobna analiza za vse zdravstvene poklice, tudi s primerjavo z drugimi dr‘avami. V obdobju 1973 do 1983 so ugotavljali hitro rast {tevila zdravnikov prakti~no na vseh podro~jih zdravstvene dejavnosti (od 3,3 do 6,3%), razen na zavodih za socialno medicino in higieno (pri slednjih upad za 0,5%). Druga analiza iz istega obdobja, katere nosilec je bila prav tako Ravnikarjeva, je pravzaprav povzetek ugotovitev iz prej{nje analize z umestitvijo rezultatov v demografske razmere in tedanje projekcije prebivalstva Slovenije. Gradivo je pripravljeno v taki obliki, da omogo~a ravni, ki v zdravstvu in zdravstveni politiki odlo~a presojo o potrebah po vseh profilih zdravstvenih delavcev. Primerjavo med evropskimi razmerami in razmerami v Severni Ameriki dobro prikazujejo kazalci Svetovne zdravstvene organizacije ”Zdravje za vse do leta 2000”, ki se nana{ajo na preskrbljenost z zdravniki in zobozdravniki v nekaterih izbranih evropskih dr‘avah. (Tabeli 2 in 3). Slovenija ima pomemben geopoliti~ni polo‘aj v Evropi (25). Leta 1992 smo sprejeli novo zdravstveno zakonodajo. Z odprtjem meja lahko pri~akujemo, da se bodo zdravstvenim izvajalcem pokazale nove prilo‘nosti. Po mednarodnih izku{njah bodo najve~je prilo‘nosti v plasti~ni, ‘ilni kirurgiji, ortopediji, ginekologiji, rehabilitaciji, zdravili{kem zdravljenju in zobozdravstvu. Za tujce je posebej atraktivno na{e zobozdravstvo zaradi ni‘jih cen storitev. 102 Zdrav Var 2006; 45 Tabela 1. Primerjalna predstavitev podatkov iz analize (24) in dejanskega stanja {tevila zdravnikov in zobozdravnikov. Table 1. Comparison of active doctor and dentist workforce statistics (24). Poklic / Profession Analiza (24) / Analysis Dejansko stanje / Situation on 31.12.1980 Dejansko stanje / Situation on 31.12.1990 Dejansko stanje / Situation 31.12.2002 Zdravniki v osnovnem zdravstvenem varstvu / physicians in primary health care 1165 1272 1707 (ZD) 1520 (javni / public sphere -1242 zasebniki / private sector - 278) Zobozdravniki v osnov. zdravstvenem varstvu / dentists in primary health care 896 816 1052 (ZD) 1122 javni / public -552 zasebniki / private -570) Zdravniki v bolnišnični in special. dejavnosti / physicians employed in hospitals and specialist 1566 1471 1935 2720 Zdravniki na zavodih za soc. med. in higieno / dentists employed in centres of social medicine and hygiene 81 71 108 95 Zdravniki SKUPAJ /TOTAL doctors 3708 3630 4802 5457 Vir: Zdravstveni statisti~ni letopis Slovenija 1990 in 2002, IVZ RS / Source: Health Statistical Yearbook of the Republic of Slovenia for 1990 and 2002, Institute of Public Health of the Republic of Slovenia Na~rtovalci zdravstvene politike morajo te prilo‘nosti vzeti v zakup in ponovno ovrednotiti zdravstvene strategije na osnovah poslovne odli~nosti in mednarodnih standardov. Mobilnost delovne sile lahko Sloveniji koristi. V Sloveniji bo v prihodnjih letih primanjkovalo 700 zdravnikov (17% vseh zdravstvenih delavcev). Zdravni{ke pla~e so v zadnjih letih mo~no narasle, tako da stro{ki celotne delovne sile predstavljajo 60% stro{kov bolni{ni~nega zdravljenja, leta 1993 pa so zna{ale le 40% (26). Stro{ki delovne sile so na zgornji meji. Ti stro{ki lahko dvignejo cene zdravstvenih storitev do ravni, ko za sosede ne bomo ve~ konkuren~ni. Po podatkih iz leta 2000 je v Sloveniji primanjkovalo 0,65 do 1,2% zdravnikov od vseh aktivnih zdravnikov. 3% zaposlenih zdravnikov je bilo tujcev. Skupaj je primanjkovalo 4% zdravnikov, kar ustreza eni generaciji diplomantov medicinske fakultete v Ljubljani (11). V ~asu prvega nacionalnega razpisa specializacij zdravnikov v letu 2003 so izvajalci zdravstvene dejavnosti za obdobje 2007 do 2010 izrazili potrebe po skupni zaposlitvi 880 novih specialistov. Zdravni{ka zbornica je v okvirih realne ponudbe zdravni{ke delovne sile pri oblikovanju dokon~nega razpisa upo{tevala {e podatke o potrebnem nadome{~anju zdravnikov za obnavljanje obstoje~e mre‘e zdravni{kih delovnih mest glede na register zdravnikov, korekcije na osnovi podatkov o povpre~ni preskrbljenosti prebivalstva s specialisti v razli~nih slovenskih regijah in cilje plana zdravstvenega varstva, a tudi omejitve zaradi premajhnega {tevila specializacijskih delovnih mest. Tako je bilo kon~no skupno {tevilo specializacij v 1. nacionalnem razpisu 254, izkazala pa se je tudi usklajenost med Zbornico in Ministrstvom za zdravje tako glede novih pravil igre na podro~ju specializacij kot glede na~rtovanega {tevila razpisnih specializacij (27, 28). Razpravljanje Splo{ne ugotovitve V preteklosti narejena {tudija je kot temeljna rezultata poudarila dvoje: prvi~, nadaljevanje nara{~anja {tevila zdravnikov v prakti~no vseh obravnavanih dr‘avah, vendar z ‘e opaznimi u~inki za zmanj{evanje {tevila vpisanih {tudentov v nekaterih med njimi; drugi~ pa, da bo t.i. “baby-boom” generacija zdravnikov, ki so vstopili v velikem {tevilu v dejavno poklicno ‘ivljenje, odhajala v pokoj kmalu po letu 2000 (30). Prva ugotovitev za Slovenijo prakti~no ne velja, saj je vpis Grmek-Ko{nik I., Albreht T. Na~rtovanje {tevila zdravnikov in zobozdravnikov v zdravstvu - metode, uporabnost, ... 103 na Medicinsko fakulteto v Ljubljani nadzorovan (omejen) ‘e ve~ kot 30 let, zato tudi ni bilo potrebe po kakr{nih koli dodatnih ukrepih na tem podro~ju. Kar zadeva u~inek {tevil~nej{ih povojnih generacij tudi na demografske zna~ilnosti zdravnikov in zobozdravnikov, pa velja ugotoviti naslednje: pri retrogradnem pregledu podatkov ugotovimo, da se zdravni{ka populacija v Sloveniji postopoma, vendar zanesljivo, stara. To nam poka‘ejo analize starostnih skupin in povpre~na starost slovenskih zdravnikov. V Sloveniji je globalni nadzor nad {tevilom zdravnikov in zobozdravnikov ‘e ve~ kot 30 let precej natan~en. Pri tem so kazalci {tevila zdravstvenega osebja v primerjavi z dr‘avami Srednje in Vzhodne Evrope bistveno bolj ugodni. V glavnem se je nadzor izvajal z vpisno politiko Medicinske fakultete v Ljubljani, kar je tudi edini racionalni na~in nadzora nad {tevilom zdravnikov. To je imelo za posledico precej zmerno pove~evanje {tevila zdravnikov, saj smo podvojitev {tevila iz leta 1965 dosegli {ele leta 1980 (Tabela 2). Ponudba zdravnikov je bila v nekaterih intenzivnih fazah {irjenja zdravstvene mre‘e nezadostna in se je zato pokrivala z diplomanti drugih fakultet nekdanje skupne dr‘ave. V vsakem primeru smo v Sloveniji ohranili tak nadzor nad {tevilom zdravnikov, ki nas uvr{~a med dr‘ave z zelo urejenim sistemom. Tako smo leta 1997 imeli 224 zdravnikov na 100.000 prebivalcev, kar je primerljivo s cilji, ki si jih postavljajo dr‘ave z racionalnim pristopom k zdravstvenemu varstvu, kot so Velika Britanija, Kanada, ZDA in Avstralija (31). V Evropi se {tevilne dr‘ave, ki so podpirale velike zmogljivosti svojih medicinskih fakultet, danes soo~ajo s problemom zaposlovanja zdravnikov. Med temi velja omeniti predvsem {tiri dr‘ave: Italijo, Nem~ijo, [panijo in Avstrijo. Vse {tiri so imele veliko {tevilo diplomantov, ki je temeljilo na razmahu zdravstvenega varstva v teh dr‘avah v 60. in 70. letih, danes pa so te {tevilke bistveno prevelike. V pogojih gospodarske recesije in neogibne racionalizacije so tak{ni trendi nesprejemljivi. Tako je zna{al prirast zdravni{ke delovne sile leta 1999 v Nem~iji kar 5,5%, kar je ve~ od gospodarske rasti v tej dr‘avi. Zato so v vseh {tirih dr‘avah morali sprejeti bolj restriktivne ukrepe glede vpisne politike na medicinske fakultete. Tabela 2. Diplomanti medicinske fakultete - zdravniki in zobozdravniki. Table 2. Graduates from the Faculty of Medicine - doctors and dentists. Leto/Year Diplomanti-zdravniki / Medical graduates Diplomanti-zobozdravniki / Dental graduates 1986 91 33 1987 138 17 1988 124 31 1989 114 27 1990 127 33 1991 112 29 1992 105 31 1993 125 27 1994 108 38 1995 157 41 1996 140 25 1997 119 41 1998 125 38 1999 136 16 2000 105 43 2001 122 43 2002 151 30 Vir: Zdravstveni statisti~ni letopis 2002 (29) / Source: Health Statistical Yearbook 2002 (29) 104 Zdrav Var 2006; 45 Analize, ki so bile opravljene v pripravah planskih gradiv za Dr‘avni zbor, predvidevajo mnogo bolj umirjeno rast {tevila zdravnikov in zobozdravnikov, kot pa smo ji bili pri~a v preteklih treh desetletjih. Predvidena rast povpra{evanja po zdravnikih je na ravni 0,5% letno. To je minimalna rast, zasnovana na trendih zadnjih let, ob upo{tevanju rasti povpra{evanja glede na demografske zna~ilnosti prebivalstva Slovenije - bistveno zmanj{anje {tevila rojstev in staranje prebivalstva. Kot je razvidno iz predvidevanj, ki jih uporabljamo, bodo klju~ni dejavnik v definiranju potreb po zdravnikih demografski kazalci zdravni{ke populacije same (21). V zadnjih letih se v Sloveniji ob nadaljnji veljavi stati~nega modela rasti zaposlovanja in obsega zdravstvene dejavnosti ‘e ka‘e pomanjkanje zdravnikov. Vzroki za to so: spremenjena zakonodaja s strani EU glede dovoljenega dela zunaj rednega delovnega ~asa, ki dovoljuje manj{e {tevilo de‘urnih ur, ~eprav je treba zagotavljati 24-urno urgentno slu‘bo. Pribli‘no dve tretjini zdravnikov je ‘ensk, zato so v reproduktivni dobi ve~ let odsotne. Trajanje specializacij se je v zadnjih letih podalj{alo s 4 let na 6 let. Specializacija lahko zajame tudi del sekundarijata, zato gre trenutno za enoletni primanjkljaj specialistov razli~nih specialnosti. Zdravniki, starej{i od 50 let, so po delovni zakonodaji opravi~eni od no~nega dela in stanja pripravljenosti. Sedanja specializacija splo{ne oz. dru‘inske medicine je pridobila novo obliko, ki Tabela 3. Klju~ni kazalci slovenskega zdravstvenega sistema v primerjavi z nekaterimi drugimi evropskimi dr‘avami (Avstrija, Nem~ija, Nizozemska, Velika Britanija in dr‘avami EU). Table 3. Key health care indicators for Slovenia and several other European countries (Austria,Germany, the Netherlands, Great Britain and EU member countries). Enota / Unit SI /SI A/A ZRN/GER NL/NL VB/GB EU /EU Zmogljivosti in izraba / Supply and utilization 1997 1997 1997 1997 1997 1996 Zdravniki na 1.000 preb. / Physicians per 1000 population Število 2.24 3.60 3.45 1.80 1.53 3.46 Spi. zdravniki na 1.000 preb. / GPs per 1000 population Število 0.7 0.5 0.7 0.8 0.6 1.00 Obiski na prebivalca /Visits per nhabitant Število 6.4 6.3 13.0 5.9 5.9 7.3 Zobozdravniki na 1.000 preb. / Dentists per 1000 population Število 0.64 0.48 0.76 0.52 0.32 0.68 Farmacevti na 1.000 preb. / Pharmacists per 1000 population Število 0.34 0.55 0.57 0.17 0.36 0.78 Predpisani zavitki zdravil na prebivalca / Drugs prescribed per inhabitant Število 15.60 17.20 11.60 9.80 Bolnišnične postelje na 1.000 preb. / Hospital beds per 1000 population Število 5.8 8.9 9.4 5.5 4.9 7.3 Bolnišnično zdravljenje na 1.000 preb. / Hospital admissions per 1000 population Število 16.9 24.6 20.8 10.5 17.1 19.0 Povpr. trajanje boln. zdravljenja / Average hospital stay Dnevi 10.0 10.8 12.5 14.3 9.0 11.0 Stopnja zasedenosti / Bed ocupancy % 80.2 81.3 76.2 74.7 84.9 77.1 A Boln. osebje na posteljo / Hospital staff per bed Število 1.7 1.8 1.5 2.1 2.9 Boln. postelje za akut, primere na 1.000 preb. / Acute hospital beds per 1000 population Število 4.8 5.6 6.6 3.6 2.2 4.5 Vir: nacionani program zdravstvenega varstva Republike Slovenije - zdravje za vse do leta 2004 (31) / Source: National Health Care Programme of the Republic of Slovenia: Health for all by 2004 (31) Grmek-Ko{nik I., Albreht T. Na~rtovanje {tevila zdravnikov in zobozdravnikov v zdravstvu - metode, uporabnost, ... 105 zahteva ve~ kro‘enja in odsotnosti z dela. V obdobju prehoda je na {tevilo tistih kolegov, ki delajo z bolniki, vplivalo {e nekaj drugih dejavnikov. Pove~alo se je {tevilo zdravnikov, zaposlenih zunaj javne zdravstvene mre‘e, pove~ale so se mo‘nosti za zasebno delo v zdravstvu, pomembno {tevilo zdravnikov je zaradi bolj{ih pogojev poiskalo zaposlitev v novoustanovljenih predstavni{tvih mednarodnih farmacevtskih podjetij. V primerjavi z drugimi evropskimi dr‘avami imamo prakti~no najmanj{e {tevilo zdravnikov na enoto prebivalstva. Zaradi spremenjene zakonodaje o delovnem ~asu bo potrebno delo zdravnikov prek rednega ~asa dejansko zmanj{ati. Nujno bo potrebno pove~ati tudi obseg programa dolo~enih dejavnosti. Ob nadaljevanju sedanjih trendov povpra{evanja po zdravni{kih in zobozdravni{kih storitvah in ob vpisu na obe fakulteti lahko ocenimo, da se bo vsaj {e nekaj let nadaljeval trend zmanj{evanja preskrbe z zdravniki. V sodobnem planiranju kadrov je neobhodna ra~unalni{ka tehnologija. V razvoju ra~unalni{kega sistema izvajalcev zdravstvenega varstva Slovenije so uporabili metodo informacijskega in‘eniringa, to je zbirko orodij in tehnik za planiranje, analize, oblikovanje in sestavo informacijskih sistemov (32). Mre‘a izvajalcev zdravstvenega varstva je arhitektonsko povezana v Zavodu za zdravstveno zavarovanje in In{titutom za varovanje zdravja, tako da je uporaba baze dvotirna. V ZZZS slu‘i kot referen~na baza za operativno delo, v IVZ RS pa kot skladi{~e podatkov. Z zdru‘itvijo mre‘e ZZZS in IVZRS smo sposobni pripraviti hitre analize v kratkem ~asu in tudi obnavljati podatke, kar je vsekakor prednost. Zaklju~ki V zadnjih 20 letih je bilo povpra{evanje po zdravnikih v Sloveniji neustrezno glede na poklicno demografske podatke zdravnikov in zobozdravnikov, splo{no populacijsko demografsko dinamiko in razvoj novih zdravstvenih tehnologij. V prihodnjih letih bodo {tevilo aktivnih zdravnikov v glavnem zagotavljali diplomanti Medicinske fakultete v Ljubljani in po nekaj letih tudi Medicinske fakultete v Mariboru, okrog 4-8% zdravniki iz tujine, ki se bodo zaposlili v Sloveniji. Trenutno stanje na~rtovanja kadrov v zdravstvu {e vedno ni optimalno. Ministrstvo za zdravje RS, Zdravni{ka zbornica RS, Zavod za zdravstveno zavarovanje RS sogla{ajo z ustanovitvijo nacionalne komisije, ki bo pregledovala in koordinirala delo na tem podro~ju. Konflikti med vpletenimi nastajajo predvsem zaradi nejasnih pristojnosti. Potrebno bo jasneje opredeliti vloge vseh vpletenih, to so Ministrstvo za zdravje RS, Zdravni{ka zbornica RS in Zavod za zdravstveno zavarovanje RS. Literatura 1. Ryde K. Planning the medical workforce. BMJ Classified 1999; 2-3. 2. Statisti~no poro~ilo o delu zdravstvene slu‘be v SR Sloveniji za leto 1965. Zavod SRS za zdravstveno varstvo v Ljubljani, Ljubljana, decembra 1966. 3. Poro~ilo o delu zdravstvenih dejavnosti leta 1984 v SR Sloveniji. Zdrav Var 1985; Suppl : 502-515. 4. Mossberg WH. Medical Manpower Needs at Home and Abroad. Neurosurgery 1992; 30(4): 639-649. 5. Domenighetti C, Casabianca A. Economie Sanitaire, incertitude et induction de la demande par le medecin. Schweiz Med Wochenschr 1995; 125: 1969-1979. 6. Fry J. How many physicians? An enigmatic dilemma. J Roy Soc Med 1994; 87: 1-2. 7. Ryten E. Physician Workforce and Educational Planning in Canada: Has the Pendulum Swung too far? Can Med Assoc J 1995; 152(9): 1395-8. 8. Leeder SR. Australian medical svhools intake: threats to student numbers. Med J Aust 1995; 163: 324-325. 9. Hugenholtz H. The Canadian Health Care System in the Nineties. Clin Neurosurg 1994; 41: 392-411. 10. WHO Health for All Database 11. Reinhardt UE. Health Manpower Forecasting: The Case of Physician Supply. V: Ginzberg E. Health Services Research, key to health policy. Cambridge: Harvard University Press, 1991: 234-284. 12. Population projections 2004-2050: EU25 population rises until 2025, then falls. Working age population expected to decrease by 52 million by 2050. Eurostat News Release 48/2005, 8 April 2005: http://epp.eurostat.cec.eu.int/pls/portal/docs/page/ pgp_prd_cat_prerel/pge_cat_prerel_year_2005/ pge_cat_prerel_year_2005_month_04/3-08042005-en-ap.pdf. 13. Albreht T. Klazinga N. Health manpower planning in Slovenia: A policy analysis of the changes in roles of stakeholders and methodologies.J Health Polit Policy Law 2002; 27: 1001-22. 14. Zakon o zdravstvenem varstvu in zdravstvenem zavarovanju Ul RS 2004; 20: 2212-27. 15. Zakon o zdravni{ki slu‘bi. Ul RS 2003; 45: 5172-80. 16. Zakon o zdravstvenem varstvu in zdravstvenem zavarovanju. Uradni list Republike Slovenije. 17. SJM 1999/2: Stali{~a o zdravju in zdravstvu. Center za raziskovanje javnega mnenja in mno‘i~nih komunikacij, IDV, Fakulteta za dru‘bene vede, Ljubljana, 1999. 18. Zdravje v Sloveniji 1990-1999. Zdravstveno varstvo, Suppl., letn. 40. Ljubljana: In{titut za varovanje zdravja Republike Slovenije, 2001. 110 str. 19. Albreht T, ^esen M, Hindle D, Jakubowski E, Premik M, Toth M, Petric V K (ur.). Health care systems in transition : Slovenia, (European observatory on heatlh care systems, Vol. 4, No. 3). Copenhagen: European Observatory on Health Care Systems, 20.Projekt Future Patient v Sloveniji - Poro~ilo o ciljnih skupinah, Projektna skupina na In{titutu za varovanje zdravja Republike Slovenije, Ljubljana, 2001. 106 Zdrav Var 2006; 45 21. Slovenia 1997. HFA indicators. Copenhagen: WHO, 1999. 22. Albreht T. Analiza profesionalne demografije zdravnikov in zobozdravnikov v Sloveniji 1986 do 1995 z ocenami za obdobje 1996 do 2010. Zdrav Vestn 1999; 68: 647-53. 23. Kastelic I, Schlamberger K. [tevil~ni primanjkljaj zdravstvenih kadrov v lu~i kadrovskih regulativov (stanje 1.1.1972 in 1.1.1973). Zavod SR Slovenije za zdravstveno varstvo v Ljubljani, Ljubljana, 20.9.1973. 24. Kastelic I, Neubauer R, Schlamberger K, Er‘en N. Mo‘nostni {tevil~ni porast zdravstvenih kadrov v SR Sloveniji od leta 1976 do 1980, z vpogledom v {tevil~ni porast kadrov v obdobju od 1970. do 1975. leta. Zdravstveno varstvo, posebna publikacija {t.12/76. Zavod SR Slovenije za zdravstveno varstvo, Ljubljana, oktober 1976. 25. Ravnikar B, Kastelic I, Er‘en N, [egula I. Na~rtovanje {tevil~ne rasti zdravstvenih kadrov v SR Sloveniji do leta 2000 ob usklajevanju potreb in mo‘nosti izobra‘evanja. Zdravstveno varstvo, posebna publikacija {t. 1/86. Univerzitetni zavod za zdravstveno in socialno varstvo, Ljubljana, 1986. 26. Albreht T. Opportunities and challenges in the provision of cross border care: View from Slovenia. Eurohealth 2002; 8 (4): 1-3. 27. Poslovno poro~ilo za leto 1993. Novis 1994; XXI (3 April 1994): 3-7. 28. Fras Z. Prvi nacionalni razpis specializacij zdravnikov – kon~no realnost. Isis 2003; 7: 25-36. 29. Zdravstveni statisti~ni letopis Slovenija 2002, IVZ RS; 2003. 30. Saugmann P. Medical Manpower in West Europe: Towards a balance between supply and demand by the Year 2000. “Medical Manpower in Europe - From surplus to deficit?”, PWG, Florence, 1991.) 31. Nacionalni program zdravstvenega varstva republike Slovenije - zdravje za vse do leta 2004. Uradni list Republike Slovenije 2000; 49: 6650-6677. 32. Albreht T, Paulin M. National Health care Providers’ database (NHCPD) of Slovenia - Information technology solution for health care planning and management. V: Kokol, P (ur.), Zupan B (ur.), Stare J (ur.), Premik M (ur.), Engelbrecht R (ur.). Medical Informatics Europe ’99, (Studies in health technology and informatics, vol. 68). Amsterdam [etc.]: IOS Press; Tokyo: Ohmsha, cop. 1999, str. 165-170. Zdrav Var 2006; 45: 107-111 107 BIOTERRORISM AND PUBLIC HEALTH - PREPAREDNESS FOR IMMEDIATE ACTION BIOTERORIZEM IN JAVNO ZDRAVJE - PRIPRAVA NA HITRI ODGOVOR Mirjana Stanti~-Pavlini~1 Prispelo: 29. 3. 2005 - Sprejeto: 11. 12. 2005 Review article UDC 614.8:340.62 Abstract Work plans of the Council of EU for 2003-2008, and work plan 2005 of EU and Ministry of Health of the Republic of Republic Slovenia stress the need for preparedness for health threats. Different kinds of microorganisms and their natural toxins have been recognised as potential threats in event of bioterroristic attack. Most of them are rarely reported because of their nonspecific clinical features and complex laboratory confirmation. Some diseases are easily propagated from person to person, or from animals to humans, and some are not highly contagious. The degree of public health threat they represent depends on the level of awareness, knowledge and preparedness for a rapid response in different institutions, including health care settings. Key words: bioterrorism, public health, microbiology, bacterial toxins, disease notification Pregledni znanstveni ~lanek UDK 614.8:340.62 Izvle~ek Usmeritve Delovnega na~r ta Evropske skupnosti za obdobje 2003-2008 ter Delovnega na~rta EU in Ministrstva za zdravje Republike Slovenije za leto 2005 narekujejo izbolj{avo pripravljenosti na nenadne dogodke, ki lahko vplivajo na zdravje prebivalstva. Razli~ne mikroorganizme ter njihove naravne toksine uvr{~amo med morebitne agense napada. Ve~ji del teh povzro~iteljev redko zaznamo oz. o njih poro~amo zaradi velikokrat nespecifi~ne bolezenske slike ali zahtevne mikrobiolo{ke laboratorijske diagnostike. Nekatere bolezni se hitro prena{ajo od ~loveka na ~loveka ali z ‘ivali na ~loveka, druge pa ne sodijo med visoko nalezljive bolezni. Nevarnost za javno zdravje je odvisna od zavesti, znanja in pripravljenosti razli~nih slu‘b, vklju~no z zdravstvom, za hitri odgovor na razli~no ogro‘anje javnega zdravja. Klju~ne besede: bioterorizem, javno zdravje, mikrobiologija, bakterijski toksini, prijave bolezni Introduction The European Parliament and the Council adopted a Decision establishing a programme of Community action in the field of public health, 2003-2008 (1). European Union (2) and Ministry of Health of the Republic of Slovenia (3) adopted working programmes for 2005. All the above mentioned documents give priority to rapid action-oriented response to public health threats. 1Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana Correspondence to: e-mail: stantic@bigfoot.com One of the achievements of health care in the past century is easy access to preventive medicine, i.e. to immunisation, screening, health education and preventive treatment. At the same time, rapid progress in the development of biological weapons was notified (4). Last years, a large number of publications have been published all over the world dealing with health protection against bioterrorism. 108 Zdrav Var 2006; 45 All the decisions taken should be professional and based upon proper medical evaluation and training of all services engaged in reducing the harm of biological attack. Prompt decisions and actions should be based on carefully prepared plans. Preventing general fear and panic is part of a rapid response to a potential attack. The response should be well coordinated between the government and various public health institutions. Emergency personnel should immediately locate and identify the contaminated area. They may have to act within minutes if lifes are to be saved. A covert release of a biological agent may not be noticed for days or even weeks, depending on the incubation period. The disease may spread to other parts of the country or world because of movement of victims during the symptom-free incubation period after the exposure. Definition of biological weapon World Health Organisation (WHO) defines biological weapons as ones whose intended target effects are due to the infectivity of disease-causing microorganisms (5). Predictions Nearly any infectious disease can occur as a result of biological attack. Some of them are transmitted via respiratory or alimentary route, or through contacts with contaminated environment or animals (6). Infections as a result of ingestion of contaminated food or water can be expected as well (7, 8). The onset of the disease can be abrupt, or progressive over several days or weeks, depending on the incubation time. Some diseases are propagated from person to person. Clinical presentation of infectious diseases varies largely, and depends on the kind of microorganisms used in biological terrorism attack (9, 10, 11). Bioterrorist attacks usually create general panic in the affected region. As a result, victims of panic and those in need of medical care seek immediate medical attention in the nearest health care institutions. They mostly arrange for their own transport to the hospital rather than wait for the arrival of rescuers. Measures should be taken to prevent the dissemination of infectious disease at the site of attack, in the nearby primary health care institutions and in the closest hospitals. Decontamination of casualties should be planned for all these settings. Security workers and medical personnel should be available to combat panic, solve traffic and telecommunication problems and meet needs for medical care. Safeguards and health care personnel should be protected against vaccine-preventable infectious diseases by immunization. If there is a high risk of some uncommon diseases, additional vaccination against emerging infectious diseases is required. Prophylactic medication is recommended for protection against diseases preventable by prophylactic treatment (12). Assessing the threats to public health Many pathogens have been investigated for their potential use as biological weapons, but few have been found satisfactory candidates, and even fewer have actually been used. Biological agents listed as possible weapons for use against human beings by WHO (5), United Nations (13), NATO (4) and Australia group (14) include: • Bacillus anthracis, • Brucella species, • Burkholderia psuedomallei, • Franciscella tularensis, • Yersinia pestis, • Coxiella burnetii, • Rickettsia prowazeki, • Rickettsia rickettsii, • Tick-borne encephalitis, • Dengue, • Yellow fever, • Eastern equine encephalitis, • Chikungunya, • Venezuelan equine encephalitis, • Var iola major (smallpox), • Others The United Nations define bioterrorism as the unlawful use, or threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. Medical aspects Various methods of disseminating biological agents are available. The most likely route of transmission, which poses the highest risk, is inhalation of microorganisms. Only few bioagents penetrate the skin, but many can enter the digestive system with contaminated food or drinking water. Infection may also be transmitted by a hand-mouth contact after touching contaminated surfaces. Stanti~-Pavlini~ M. Bioterrorism and public health - preparedness for immediate action 109 Clinical presentation of diseases caused by biological attack is usually delayed, with exception of some toxins. A considerable interval may elapse between a biological attack and identification of the first cases of disease. The patients may present with atypical early clinical findings. Epidemiological investigation is required to determine symptoms of the disease, mode of microorganism transmission and source of infection10. Mixed infections or intoxications with two or more different pathogens are possible, and they are likely to complicate or delay the diagnosis. Attack indicators are as follows: • a disease pattern may differ from a naturally-occurring epidemics in a known geographic area; • severe respiratory involvement; • resistance of microorganisms to usually used antibiotics; • occurrence of “old” or newly identified infectious diseases in regions where they occur very rarely or had been eradicated; • increased numbers of sick or dead animals, witness to an attack, or discovery of an appropriate delivery system. Incubation period The interval between infection of an individual and the onset of symptoms depends on (15): • the infecting microorganism; • virulence of the particular strain of the causative agent; • infecting dose and route of infection; • host susceptibility. The incubation period of pathogens ranges from several hours (food poisoning), to several days (plague) weeks (smallpox, Q-fever) or even months (anthrax) (16,17). The incubation period after the use of a toxin is usually shorter, i.e. from a few minutes to several hours for T-toxin, Staphylococcal toxin or castor oil. During the incubation period, except just before the disease onset, the infected person is usually not able to transmit the disease to another person. Immediately upon the identification of a bioterrorist attack, decontamination of the contaminated environment should be started. Notifiable diseases Many infectious diseases (18) are notifiable under the public health regulations (Table 1). Many diseases are likely to be caused by a biological attack. Local health care institutions and the Institute of Public Health of the Republic of Slovenia are responsible for infectious disease control in Slovenia. Doctors have to send reports on infectious diseases to the regional Institute of Public Health. Epidemiological investigations and control measures are required to limit the spread of infection. Data should be collected from a variety of sources with the aim provide effective disease surveillance, including the following activities: • facilitating early identification of changes in disease patterns; • identifying changes in environmental and host factors that may lead to an increase in the frequency of disease; • monitoring the safety and effectiveness of preventive and control measures. Epidemics An epidemic is characterised by a temporary increase in the incidence of infectious disease. Most epidemics are public health emergencies and require prompt identification of infectious agent and effective control measures. The course of an epidemic depends on the biological properties of the agent, on whether the environment is favourable to its survival and transmission, and on the immunity of the host population. Epidemics are most commonly caused by microbials, but may also be due to bacterial toxins or chemical poisoning. There are two main types of epidemics: • common source, • propagated. Both of them can occur as a result of a biological attack. International assistance According to the WHO most countries can make a major contribution to the preparedness for deliberate release of biological agents by strengthening public health infrastructure, particularly public health surveillance and response. International assistance is of primary importance and falls into the following categories: • application of international law; • medical and other assistance; • practical protection (provision of equipment, and of material, scientific and technical information). 110 Zdrav Var 2006; 45 Table 1. Notifiable infectious diseases in Slovenia. Tabela 1. Infekcijske bolezni, ki jih je treba v Sloveniji obvezno prijaviti. AIDS/HIV Anthrax / Vranični prisad Botulismus / Botulizem Brucellosis / Bruceloza Cholera / Kolera Diphtheria / Davica Dysentery (amebic and bacillary) / Griža (povzročitelj: ameba ali bakterije) Echinococcosis / Ehinokokoza Encephalitis / Encefalitis Enterobiasis / Enterbioza Enterocolitis / Enterokolitis Febris haemorrhagica virosa / Hemoragična mrzlica Febris Q / Vročica Q Gonorrhea / Gonoreja Influenza / Influenca Lambliasis / Lamblioza Legionelosis / Legioneloza Leptospirosis / Leptospiroza Lyme disease / borelioza Lymska Malaria / Malarija Malleus / Smrkavost Measles / Ošpice Meningitis / Meningitis Meningococcal septicaemia / Meningokokna sepsa Microsporiasis / Mikrosporija Mononucleosis infectiosa / Infekcijska mononukleoza Mumps /Mumps Morbilli /Ošpice Morbus Brill-Zinsser/ Brill-Zinserjeva bolezen Pertussis / Oslovski kašelj Plague / Kuga Paratyphoid fever / Paratifus Poliomyelitis / Poliomielitis Psittacosis / Psitakoza Rabies / Steklina Relapsing fever / Povratna mrzlica Rubella / Rdečke Scarlat fever / Škrlatinka Tetanus/Tetanus Tuberculosis / Tuberkoloza Tularemia /Tularemija Typhus abdominalis / Trebušni tifus Viral haemorrhagic fever / Hemoragična mrzlica Viral hepatitises / virusni hepatitis Whooping cough / Oslovski kašelj Yellow fever/ Rumena mrzlica Some others / nekatere druge bolezni The United Nations with various agencies or related organizations will advise and assist national governments in developing and maintaining global defense against biological weapons (13). Preventive measures A rapid and coordinated action will be necessary to identify the cause and to institute effective control measures (19). First responders to an attack with toxic substances or biological weapons with prompt effects will most likely be police and fire department personnel, while first responders to an initially undetected attack with an infective agent, or with a toxic agent with delayed effects, will more likely be health care personnel. Protection measures for first responders include: • impermeable surgical gowns; • oral-nasal masks; • face shields or goggles; • vaccination; • preventive medication. Separation of contaminated victims of bioattack and implementation of barrier nursing procedures should be initiated immediately. Preventive treatment and vaccination should follow laboratory confirmation of causative agent. Conclusion There is a need for intensified activities in the field of protection and defence against bioterorrism on the Stanti~-Pavlini~ M. Bioterrorism and public health - preparedness for immediate action 111 national level. Slovenia can participate with the knowledge and experience of civil defence experts, Red Cross, microbiological laboratories, and public health workers from government ministries and public health institutions. National action plan will be designed in accordance with the WHO, EU and the United Nations directions. References 9. Stantic-Pavlinic M, [ek S. Biological and chemical terrorism. Manual. Ljubljana: Institute of Public Health of Ljubljana, 2002: 1-137(Slo). 10. Dennis DT, Iglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Fine AD, Friedlande AM, Hauer J, Layton M, Lillibridge SR, McDade JE, Osterholm MT. O’Toole T, Parker G, Perl TM, Russel PK. Tonat K; Working Group on Civilian Biodefense (2001) Tularemia as a Biological Weapon. Medical and Public Health Management. Cosensus Statement. JAMA 2001; 285(21): 2763-73. 11. Karcher F, Nicoll A. 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Official Gazette of the Republic of Slovenia, No.69 /1995 (Slo). 19. Stanti~-Pavlini~ M, [ek S, Urbanc J, Vidrih R, Venin{ek-Perpar I, Mehiki~ D. The assessment of Health Risks associated with drinking water in the earthquake. In: Abstract book. 1. Slovenian Conference on catastrophic and military medicine; 2000 Sept 6-9; Portoro‘. Ljubljana: Ministry of Health of Republic of Slovenia, 2000; 12. 1. EU. Decision No 1786/2002/EC of the European Parliament and of the council of 23 September 2002, adopting a programme of Community action in the field of public health (2003-2008). Official Journal of the European Communities, dne 12.10.2002; L 271/1-11. http://europa.eu.int/comm/health/ph_programme/ programme_en.htm. 2. EU. Community action in the field of public health (2003-2008) Work plan 2005 http://europa.eu.int/comm/health/ ph_programme/howtoapply/proposal_docs/ workplan2005_en.pdf. 3. Working Programme of Ministry of Health of Republic of Slovenia for 2005. http://www2.gov.si/mz/mz-splet.nsf. 4. First Responder Chem-Bio Handbook. Practical Manual for First Responders. Alexandria, VA, USA: Tempest Publishing, 1998. 5. WHO. Health Aspects of Biological and Chemical Weapons. 2.edition. WHO, 2001. 6. Giesecke J. Modern Infectious Disease Epidemiology. New York: Oxford University Press, 1995. 7. Khan AS, Sage MS. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. MMWR 2000; 49(RR-4): 1-14. 8. Peng MM, Matos O, Gatei W, Das P, Stantic-Pavlinic M, Bern C, Sulaiman IM, Glaberman S, Lal AA, Xiao L. A comparison of Cryptosporidium subgenotypes from several geographic regions. J Eukaryot Microbiol. 2001; Suppl: 28S-31S. 112 Zdrav Var 2006; 45: 112-113 EUROPEAN ACADEMIC FAMILY MEDICINE: PROSPECTS FOR THE FUTURE DRU@INSKA MEDICINA KOT EVROPSKA AKADEMSKA STROKA: OBETI ZA PRIHODNOST Francesco Carelli1 Prispelo: 2. 11. 2005 - Teaching and research developments all over Europe have contributed to the recognition of general practice/ family medicine as an academic discipline. Yet, as it has not been fully recognized in all European countries, better support is needed (1). The countries involved in EURACT (European Academy of Teachers in GP) drew up a Europe’s New Definition, signed by the main European Societies, and ratified at the 2002 WONCA Congress. It outlines the principles of the profession, and defines its own role and specialist specificity. It describes its core competencies, and opens roads for the elaboration of a specific research method, and of a teaching method based on the adopted principles and objectives (2). EURACT originally started with 15 member countries. With the publication of the Definition, this number rose to 27 and has now reached 31. It is expected to increase to 34 by the next EURACT meeting. This enlargement should increasingly strengthen the GPs’ position on the European scene, and encourage all GPs in Europe to strive for a strong and homogenous structure of general practice teaching and research. This process will definitely keep up with the political expansion of the European Union. A greater number of member countries, as well as improved integration and greater homogeneity will lead to a free professional exchange and to mutual recognition of professional qualifications in many domains, including general practice. For general practice in Italy to become a recognized specialty in Europe, the general practice training course should be expanded from two to tree years. If not, European GPs will be allowed to work in Italy, while the professional qualification of their Italian colleagues will not be recognized in other European countries. This process was first promoted by some northern European countries, the so-called “first class” GP countries, which boast a long-standing and consolidated academic and departmental structure, but whose supremacy and domination, almost a monopole, in publishing, teaching and research is not looked upon with favour. - Sprejeto: 5. 1. 2006 Letter to the editor This promotion of high-level general practice in Europe enhanced the development of this discipline in the ex-Warsaw Pact countries, in line with the established model and almost at the same level. This birth of general practice “out of nothing” has been made possible thanks to local governments’ foresight and Central Bank intervention, as well as with help from experts from northern European countries. Furthermore, it fostered debate in the intermediately developed countries where there is a great number of GPs, but where family medicine is not recognized as an independent specialist discipline. National debates, often incited by the EURACT, EGPRN, EQuiP (WONCA networks) reports, opened many possibilities. National development levels varied largely, and many members submitting periodic reports to the EURACT Council reported varying degrees of progress, sometimes very small, and sometimes significant or even impressive. Even in Italy, where family medicine has not yet been fully recognized as an independent academic specialty, the first undergraduate courses have been developed; training at a national level has been consolidated and became visible, as shown by my reports for the past four years. Relevant European documents on family medicine have been placed on the agendas of political and educational debates (3). As concerns the countries that have recently joined the EU, they have reached an enviably high level of family medicine development and could therefore share their views and experience with other member countries, thereby enhancing the development and recognition of pan-European family medicine specialty. There are still considerable differences between European countries as concerns the recognition of family medicine as an academic discipline. The situation is particularly unfavourable in the Mediterranean setting (4), mostly because of political reasons and reluctance to recognize family medicine as an independent specialty: there is a delay in discussing and adopting 1EURACT Council, National Representative Correspondence to: e-mail: francesco.carelli@aliceposta.it 113 the documents related to this issue, and shortage of funding of primary care. The position of family medicine in some countries is unfavourable, as characterized by underfunding, finance cutting, and attempts to assign to GPs tasks and competencies outside their scope of practice, as, for example, in Italy (one should only read EURACT core competencies to get the true picture). Career flexibility, participation in scientific congresses and international projects, obtaining sponsorships and refunds of expenses are forbidden by laws and contracts, but just for GPs ! This policy constitutes an overt violation of the European law on free movement of doctors and mutual recognition of professional qualifications, and of the law on flexible work patterns considering one’s needs, age, work progression and competencies. Neither is it in line with the European directive stating that every medical university should have a family medicine department headed by a GP (5). GPs are prevented from engaging in real research and serene teaching in protected time. In fact, many Italian studies are conducted by a few enthusiastic “night and weekend“ researchers. In Europe, there is still a strong dichotomy between groups of countries performing quality analyses and rewarding quality in practice, i.e. by work contracts (6), and between groups of countries where contracts are based on quantity, e.g.on the number of patients on lists, number of patients or procedures per time unit, which is the case in Spain, Italy, Romania and Bulgaria. It is not by coincidence that in a European research project on burn-out effects in GPs, Bulgaria performed the worst, and that many lawsuits in the country involve medical errors caused by excessive workload, lack of motivation, and depression (7). The domain of family medicine, however, is apparently making a rapid progress in some European countries. These include: Malta, a country with a small group of GPs with a homogenous, European mentality; Turkey which boasts 23 university family medicine departments, and Slovenia, a small country with national representatives at the highest levels in European GP organizations. In order to promote the academic development of general practice, and to achieve and maintain high quality standards in this discipline, it is necessary to put pressure on governments and to insist on the application of the published directives in practice. It is also necessary to make the discipline more attractive for medical students and young physicians, to develop and spread teaching and research methods, and to put forward new ideas and proposals to increase the effectiveness of clinical care and specific services in general practice (8). The most important recent contribution of academic general practice has been the definition of an educational agenda, meeting the needs of physicians, future GPs, health services, patients and other specialists (9). General practice as an independent academic discipline should also strive for equity in health and health care, an important topic for a general practice/family medicine research agenda. Increasing the available research capacities, and developing practice-based research networks should become a key priority for any country (10). At the same time, cooperation processes should be proposed within the European networks, aiming to further enhance and integrate their productivity. Various and more senior GP posts are required to fulfill the tasks and aims of academic leadership in the countries where it is still lacking. Appointments to these posts should always be made according to real objectives and transparent criteria of professional quality. In those countries where GPs still perceive themselves as being at the bottom of the academic scale, measures should be taken towards the establishment of a national career structure for academic general practice (11, 12). These activities, together with the implementation of the educational and research agendas, will really promote a wider and more homogeneous development of general practice/family medicine as a specific academic discipline in Europe. References 1. Jones R. Academic family practice. Fam Pract 2003; 20: 359. 2. Allen J, Gay B, Crebolder H, Svab I, Evans P. - WONCA-Europe - The New Definition, London, 2002. 3. EURACT website - www.euract.org - Council Meetings. 4. Lionis C, Carelli F, Soler JK. - Developing academic careers in family medicine within Mediterranean setting. Fam Pract 2004; 21(5): 477-478. 5. WHO-WONCA - Framework on General Practice, Geneve 1998. 6. Spooner A. - Quality in the new GP Contract - 2004, Radcliffe Medical Press. 7. Carelli F. - The GPs’ burn-out syndrome and the intolerable pressure felt as an institutional mobbing. Oral Presentation -ID: 125 - 16th Annual Scientific Meeting 2005, Royal College of General Practitioners in London - 22 August 2005. 8. Carelli F. - Undergraduate teaching of family medicine in Italy: the Modena model. Eur J Gen Pract 2003; 9: 121. 9. Heyrman J. and EURACT Council - The EURACT Educational Agenda of General Practice / Family Medicine - Leuven 2005. 10. Van Weel C, Rosser C. - Improving health globally: the necessity for family medicine research - a critical review of its implications and recommendations to build its capacity. Ann Fam Med 2004; 52-54. 11. Carelli F, Lionis C, Rebhandl E, Zebiene E, Wallace P. - Towards a career flexible development for General Practitioners: possibility for a career, for dignity, against burn out. -Symposium - Paper n. 496 - European WONCA Congress, Ljubljana (Slovenia), June 2003. 12. Carelli F, Howe A, Lionis C, Svab I, Allen J. - General Practitioners’ Career: towards academic level and towards flexible development: why and how - Symposium - Paper n. 20 - European WONCA Comgress, Amsterdam (the Netherlands), June 2004. 114 Zdrav Var 2006; 45: 114-115 SEMINAR KATASTROFNE MEDICINE Mirjana Stanti~-Pavlini~1 Poro~ilo Seminar o t.i. katastrofni medicini, poimenovan Pripravljenost zdravstvenih zavodov za velike nesre~e - pandemija gripe in kemijske nesre~e, je potekal 15. in 16. februarja 2006 v Ljubljani. Seminar je organiziralo Ministrstvo za zdravje RS. Na sre~anje so bili povabljeni tisti, ki se v zavodih ukvarjajo z na~rtovanjem in izvajanjem dejavnosti na podro~ju katastrofne medicine ter izvajalci nujne medicinske pomo~i. Povabljeni so bili vsi zdravstveni zavodi in zasebniki. Obravnavali smo pripravljenost zdravstvenih zavodov za velike nesre~e. Sre~anje se je za~elo z informacijo o vaji EU, ki se je nana{ala na pandemijo gripe, pregledali smo vzor~ni primer na~rtov posameznih zdravstvenih zavodov in se dogovorili za nadaljnje dejavnosti v zvezi z organizacijo in ukrepanjem na podro~ju zdravstva. V sodelovanju z Uradom za kemikalije, Klini~nim centrom - Centrom za zastrupitve in v okviru programa PHARE - Chemical safety II je bil pripravljen uvodni del usposabljanja za podro~je kemijskih nesre~, predstavljene so bile tudi izku{nje kolegov iz Avstrije. Na podlagi seznama potencialno nevarnih kemikalij in njihove porazdelitve po Sloveniji so kolegi iz Centra za zastrupitve pri Klini~nem centru v Ljubljani, predstavili toksindrome in ukrepe za zmanj{anje {kode. Gripa Usklajevanje na~rtov posameznih zdravstvenih zavodov za skupno delovanje v primeru pandemije gripe na regionalni ravni ponekod ‘e poteka. Zdravstveni dom Ljubljana sodeluje v Delovni skupini za pripravo na~rta (operativnega plana) za delovanje v izrednih razmerah_epidemija pti~je gripe Klini~nega centra v Ljubljani. Usklajujemo skupno delovanje primarnega in bolni{ni~nega zdravstvenega varstva ob morebitnem izbruhu pandemije. Podobna prizadevanja potekajo v Ptuju, Mariboru in nekaterih drugih krajih po Sloveniji. Do konca leta 2006 pri~akujemo v Sloveniji dokon~no izdelavo in sprejem Nacionalnega programa za primer pandemije gripe. Na~rtujemo nadaljnja usposabljanja zdravstvenih delavcev, vaje, ustanavljanje regijskih koordinativnih skupin, dolo~itev odgovornih oseb za sodelovanje v koordinacijski skupini. V na~rtih bo vklju~eno tudi delovanje zasebnikov ter lekarn. Dopolnjevanje na~rtov je povsod nujno. Pri~akujejo nezadostne kadrovske zmogljivosti zaradi bolni{kih odsotnosti v zdravstvu in velikih potreb prebivalstva. Finan~ne potrebe za delovanje zdravstva v kriznih razmerah po Sloveniji praviloma niso vrednotene, kar daje vtis pomanjkljivosti oz. nepopolnosti na~rtov in ote‘ko~a opremljanje z za{~itnimi sredstvi. Ministrstvo za zdravje ocenjuje, da pojav pti~je gripe med divjimi pticami v Sloveniji ne pomeni dodatne ogro‘enosti zdravja na{ega prebivalstva, kajti ni znan prenos z divje ptice na ~loveka. Kemoprofilakti~na zdravila so v Sloveniji indicirana za tiste, ki so bili v stiku z oku‘enimi pticami in za osebje, ki dela v laboratorijih za diagnostiko pti~je gripe. Tamiflu izdaja na podlagi epidemiolo{kih anketiranj In{titut za varovanje zdravja R Slovenije. Kemi~na varnost V drugem delu seminarja smo poslu{ali referate o kemijski varnosti v Sloveniji in po svetu. V Sloveniji deluje medresorska komisija za kemijsko varnost, v kateri so zastopani predstavniki {tevilnih Ministrstev in tudi Gospodarske zbornice Slovenije, policije, gasilstva. Deluje tudi stalni odbor za podro~je kemi~nih nesre~. V izdelavi je Nacionalni program za kemi~no varnost 2006-2010. Mednarodna strategija ravnanja s kemikalijami, ki je bila sprejeta februarja 2006 v Dubaju, postavlja za cilj varno uporabo kemikalij v svetovnem merilu do leta 2020. Na~rti za{~ite in re{evanja ob kemi~nih nesre~ah se ustvarjajo v Sloveniji na ravni dr‘ave, ob~in, gospodarskih dru‘b, zavodov in drugih organizacij. Nosilci na~rtovanja dolo~ijo skrbnika na~rta. Na ravni dr‘ave so razvili ra~unalni{ki geografski sistem, ki pokriva oz. spremlja kemi~no varnost v dr‘avi. Za strokovno podro~je oz. kemikalije je odgovoren Urad za kemikalije pri Ministrstvu za zdravje, za promet pa Ministrstvo za notranje zadeva in Ministrstvo za promet. Poglavitni predpisi, ki urejajo prevoz nevarnih kemikalij, sta Zakon o prevozu nevarnega blaga in Evropski sporazum o mednarodnem cestnem prevozu. Predpisi, ki so pomembni za delovanje za{~ite pred kemi~nimi 1Zdravstveni dom Ljubljana, Metelkova 9, 1000 Ljubljana Kontaktni naslov: e-po{ta: stantic@bigfoot.com 115 nesre~ami, so tudi: Zakon o kemikalijah, Pravilnik o razvr{~anju, pakiranju in ozna~evanju nevarnih pripravkov idr. Med nevarno blago uvr{~ajo strupene substance in tudi blago, ki predstavlja nevarnost za oku‘bo. O za{~itni opremi in dekontaminaciji pri morebitni uporabi kemi~nega oro‘ja smo poslu{ali zanimivo predavanje zastopnika Ministrstva za obrambo. Predstavljene so bile lastnosti lahke za{~itne obleke in tudi za{~itnih oblek, ki imajo lastnost vsrkavanja kemi~nih strupov, ne spu{~ajo strupa v telo. Nujna je tudi uporaba maske, rokavic in ustreznih {kornjev. Pri dekontaminaciji lo~ijo: • takoj{njo (osebna), • operativno (delna), • popolno, • ~istilno (clearence). Predstavljena so dekontaminacijska sredstva za dekontaminacijo vozil in terena ter lo~eno za dekontaminacijo ljudi ter tudi radiolo{ko-kemi~no-biolo{ko (RKB) za{~itni zabojnik in RKB za{~itno zakloni{~e. Na voljo je tudi razpr{ilec z antidotom za dra‘e~e pline. [tevilne kemi~ne snovi iz industrije tudi vdirajo oz. po{kodujejo ko‘o, lahko pa povzro~ajo tudi sistemske u~inke. Pred postopkom dekontaminacije sprostimo dihalne poti. Dekontaminacija o~esnih veznic traja vsaj 20 minut - izpiranje pod pipo in v ~asu prevoza. Kontaminirana obla~ila morajo biti odstranjena, bolnik ne sme kaditi, u‘ivati teko~ine ali ‘ivila. Po izpiranju {kodljive snovi bolnika prekrijemo s plastiko ali alufolijo in se pove‘emo s Centrom za zastrupitve Klini~nega centra v Ljubljani, ki je nenehno dosegljiv za nasvete (mobitel: 041 635 500). Koristne nasvete ponujajo tudi na spletni strani www.zastrupitve.net. Poudarjeno je bilo, da je strupov veliko, antidotov pa malo. Pospe{evala za eliminacijo strupa znajo biti tudi u~inkovita v nekaterih primerih. Pri du{ljivcih je na nek na~in antidot 100 odstotni kisik (ni pravi antidot), enako tudi pri zastrupitvi z ogljikovim monoksidom. Pri povzro~iteljih methemoglobinemije metilensko modrilo, pri cianidih amilnitrat, hidroksikobalamin, dikobalov edetat. Pri zastrupitvi s sulfidi amilnitrit/natrijev nitrit, pospe{ena eliminacija in hiperbari~na komora. Pri zaviralcih holinesteraze je antidot atropin v odmerku 2 do 4 mg i.v. (za otroke 0,02 mg/kg telesne te‘e i.v., ne manj kot 0,1 mg). Uporabljajo tudi obidoksim v odmerku 250 do 500 mg i.v. (otroci 4 - 8 mg na kg telesne te‘e i.v.). Dajanje atropina ponavljamo na 5 do 15 minut, obidoksima pa na 2 do 4 ure. Potreba je skrbna higiena, da se izognemo kontaktne zastrupitve zdravstvenih delavcev (ko‘a-ko‘a). Pri zastrupitvi s sarinom, ki je po teroristi~nem napadu v podzemni ‘eleznici v Tokiu pred nekaj leti zahteval so~asni transport ve~ sto bolnikov, so tudi nekateri zdravstveni delavci kazali znake mioze in glavobola. Prezra~evanje prostorov v bolni{nici je deloma bilo u~inkovito pri zmanj{evanju toksi~nih znakov pri bolnikih in zdravstvenem osebju. Kontaminirana obla~ila je potrebno 24 ur prezra~evati in potem lo~eno oprati v pralnem stroju. Ugotovili so potrebo po bolj{i opremljenosti zdravstvenih ustanov v Sloveniji in tudi re{evalnih vozil s sredstvi za za{~ito pred biolo{kimi in kemi~nimi agensi. Ugotavljajo nujnost nadaljnjega razvoja komunikacijskih sistemov in potrebo po ustanavljanje centralne baze podatkov o dostopnosti posameznih antidotov po Sloveniji. NAVODILA SODELAVCEM REVIJE ZDRAVSTVENO VARSTVO Navodila so v skladu z Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Popolna navodila so objavljena v N Engl J Med 1997; 336: 309-15 in v Ann Intern Med 1997; 126: 36-47. Uredni{tvo sprejema v obdelavo samo ~lanke, ki {e niso bili in ne bodo objavljeni drugje. Dele ~lanka, ki so povzeti po drugi literaturi (predvsem slike in tabele), mora spremljati dovoljenje avtorja in zalo‘nika prispevka, da dovoli na{i reviji reprodukcijo. Pri znanstvenih in strokovnih prispevkih morajo biti naslov, izvle~ek, klju~ne besede, tabele in podpisi k tabelam in slikam prevedeni v angle{~ino. ^e prispevek obravnava raziskave na ljudeh, mora biti iz besedila razvidno, da so bile raziskave opravljene v skladu z na~eli Helsin{ko-Tokijske deklaracije. ^e delo obravnava poskuse na ‘ivalih, mora biti iz besedila razvidno, da so bili opravljeni v skladu z eti~nimi na~eli. Avtorji, ki so v objavo poslano raziskovalno delo opravili s pomo~jo nekega podjetja, naj to navedejo v spremnem pismu. Tipkopis Prispevke po{ljite na naslov uredni{tva: In{titut za varovanje zdravja, Zdravstveno varstvo, Trubarjeva 2, SI 1000 Ljubljana. Po{ljite 3 kopije tipkanega besedila z razli~ico na disketi in originalne slike. Besedila naj bodo napisana z urejevalnikom Word for Windows. Prispevek naj bo natisnjen na belem pisarni{kem papirju z dvojnim razmikom. Robovi naj bodo {iroki najmanj 25 mm. Znanstveni ~lanki naj imajo naslednja poglavja: uvod, metode, rezultati, razpravljanje in zaklju~ek. Ostale oblike ~lankov in pregledni ~lanki so lahko zasnovani druga~e, vendar naj bo razdelitev na poglavja in podpoglavja jasno razvidna iz velikosti ~rk naslovov. Poglavja in podpoglavja naj bodo {tevil~ena dekadno po standardu SIST ISO 2145 in SIST ISO 690 (npr. 1, 1.1, 1.1.1 itd.). Prispevku naj bo prilo‘eno spremno pismo, ki ga morajo podpisati vsi avtorji. Vsebuje naj izjavo, da ~lanek {e ni bil objavljen ali poslan v objavo kak{ni drugi reviji (to ne velja za izvle~ke in poro~ila s strokovnih sre~anj), da so prispevek prebrali in se z njim strinjajo vsi avtorji. Naveden naj bo odgovorni avtor (s polnim naslovom, telefonsko {tevilko in elektronskim naslovom), ki bo skrbel za komunikacijo z uredni{tvom in ostalimi avtorji. Naslovna stran Obsega naj slovenski in angle{ki naslov ~lanka. Naslov naj bo kratek in natan~en, opisen in ne trdilen (povedi v naslovih niso dopustne). Navedena naj bodo imena piscev z natan~nimi akademskimi in strokovnimi naslovi ter popoln naslov ustanove, in{tituta ali klinike, kjer je delo nastalo. Avtorji morajo izpolnjevati pogoje za avtorstvo. Prispevati morajo k zasnovi in oblikovanju oz. analizi in interpretaciji podatkov, ~lanek morajo intelektualno zasnovati oz. ga kriti~no pregledati, strinjati se morajo s kon~no razli~ico ~lanka. Samo zbiranje podatkov ne zadostuje za avtorstvo. Izvle~ek in klju~ne besede Druga stran naj obsega izvle~ek v sloven{~ini in angle{~ini. Izvle~ek znanstvenega ~lanka naj bo strukturiran in naj ne bo dalj{i od 250 besed, izvle~ki ostalih ~lankov naj bodo nestrukturirani in naj ne presegajo 150 besed. Izvle~ek naj vsebinsko povzema in ne le na{teva bistvene vsebine dela. Izogibajte se kraticam in okraj{avam. Napisan naj bo v 3. osebi. Kadar je prispevek napisan v angle{kem jeziku, bo izvle~ek objavljen v slovenskem jeziku. Izvle~ek znanstvenega ~lanka naj povzema namen dela, osnovne metode, glavne izsledke in njihovo statisti~no pomembnost ter poglavitne sklepe. Navedenih naj bo 3-10 klju~nih besed, ki nam bodo v pomo~ pri indeksiranju. Uporabljajte izraze iz MeSH - Medical Subject Headings, ki jih navaja Index Medicus. Praviloma naj bo izvle~ek oblikovan v enem odstavku, izjemoma v ve~ih. Kategorijo prispevka naj predlaga avtor, kon~no odlo~itev pa sprejme urednik na osnovi predloga recenzenta. Reference Vsako navajanje trditev ali dognanj drugih morate podpreti z referenco. Reference naj bodo v besedilu navedene po vrstnem redu, tako kot se pojavljajo. Referenca naj bo navedena na koncu citirane trditve. Reference v besedilu, slikah in tabelah navedite v oklepaju z arabskimi {tevilkami. Reference, ki se pojavljajo samo v tabelah ali slikah, naj bodo o{tevil~ene tako, kot se bodo pojavile v besedilu. Kot referenc ne navajajte izvle~kov in osebnih dogovorov (slednje je lahko navedeno v besedilu). Seznam citirane literature dodajte na koncu prispevka. Literaturo citirajte po prilo`enih navodilih, ki so v skladu s tistimi, ki jih uporablja ameri{ka National Library of Medicine v Index Medicus. Imena revij kraj{ajte tako, kot dolo~a Index Medicus (popoln seznam na naslovu URL: http://www.nlm.nih.gov). Navedite imena vseh avtorjev, v primeru, da je avtorjev {est ali ve~, navedite prvih {est avtorjev in dodajte et al. Primeri za citiranje literature: primer za knjigo: 1. Premik M. Uvod v epidemiologijo. Ljubljana: Medicinska fakulteta, 1998. 2. Mahy BWJ. A dictionary of virology (2nd ed.). San Diego, Academic Press, 1997. primer za poglavje iz knjige: 3. Urlep F. Razvoj osnovnega zdravstva v Sloveniji zadnjih 130 let. In: [vab I, Rotar-Pavli~ D, editors. Dru`inska medicina, Ljubljana, Zdru`enje zdravnikov dru`inske medicine, 2002: 18-27. 4. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 1999: 32-6. primer za ~lanek iz revije: 5. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled trial of telephone management of suspected urinary tract infections in women. J Fam Pract 2001; 50: 589-94. primer za ~lanek iz revije, kjer avtor ni znan: 6. Anon. Early drinking said to increase alcoholism risk. Globe 1998; 2: 8-10. primer za ~lanek iz revije, kjer je avtor organizacija: 7. Women’s Concerns Study Group. Raising concerns about family history of breast cancer in primary care consultations: prospective, population based study. BMJ 2001; 322: 27-8. primer za ~lanek iz suplementa revije z volumnom, s {tevilko: 8. Shen HM, Zhang QF. Risk assessment of nickel carcinogenicity and occupational lung cancer. Environ Health Perspect 1994; 102 Suppl 2: 275-82. 9. Payne DK, Sullivan MD, Massie MJ. Women’s psychological reactions to breast cancer. Semin Oncol 1996; 23 (1 Suppl 2): 89-97. primer za ~lanek iz zbornika referatov: 10. Sugden K. et al. Suicides and non-suicidal deaths in Slovenia: Molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick : University of Oxford, 2002: 76. primer za magistrske naloge, doktorske disertacije in Pre{ernove nagrade: 11. Bartol T. Vrednotenje biotehni{kih informacij o rastlinskih drogah v dostopnih virih v Sloveniji. Doktorska disertacija. Ljubljana, Biotehni{ka fakulteta, 1998. primer za elektronske vire: 12. Mendels P. Textbook publishers extend lessons online. Pridobljeno 23.9.1999 s spletne strani: http://www.nytimes.com/ library/tech/99/09. Tabele Naj bodo natipkane v besedilu prispevka na mestu, kamor sodijo. Tabelo naj sestavljajo vrstice in stolpci, ki se sekajo v poljih. Tabele o{tevil~ite po vrstnem redu, vsaka tabela mora biti citirana v besedilu. Tabela naj bo opremljena s kratkim naslovom. Pojasnjene naj bodo vse kratice, okraj{ave in nestandardne enote, ki se pojavljajo v tabeli. Slike Morajo biti profesionalno izdelane. Pri pripravi slik upo{tevajte, da gre za ~rno-beli tisk. Slikovno gradivo naj bo pripravljeno: • ~rno-belo (ne v barvah!); • brez polnih povr{in, namesto tega je treba izbrati {rafure (~e gre za stolpce, t. i. tortice ali zemljevide); • v linijskih grafih naj se posamezne linije prav tako lo~ijo med seboj z razli~nim ~rtkanjem ali razli~nim ozna~evanjem (s trikotniki, z zvezdicami...), ne pa z barvo; • v grafih naj bo ozadje belo (tj. brez ozadja). ^rke, {tevilke ali simboli na sliki morajo biti jasni, enotni in dovolj veliki, da so berljivi tudi na pomanj{ani sliki. Ro~no ali na pisalni stroj izpisano besedilo v sliki je nedopustno. Oddajte originale slik oz. fotografije. Prosimo, da slik ne skenirate sami. Na zadnji strani fotografije naj bo napisana zaporedna {tevilka fotografije, ime pisca in naslov ~lanka, v dvomljivih primerih naj bo ozna~eno, kaj na sliki je zgoraj oz. spodaj. Slike, narisane v ra~unalni{kih programih, naj bodo posnete v originalnem programu na disketi. Fotografije iz rentgenogranov in diapozitivov naj priskrbi avtor sam. Vsaka slika mora biti navedena v besedilu. Besedilo k sliki naj vsebuje naslov slike in potrebno razlago vsebine. Slika naj bo razumljiva tudi brez branja ostalega besedila. Pojasniti morate vse okraj{ave s slike. Uporaba okraj{av v besedilu k sliki je nedopustna. Besedila k slikam naj bodo napisana na mestu pojavljanja v besedilu. Fotografijam, na katerih se lahko prepozna identiteta bolnika, prilo‘ite pisno dovoljenje bolnika. Merske enote naj bodo v skladu z mednarodnim sistemom enot (SI). Kraticam in okraj{avam se izogibajte, izjema so mednarodno veljavne oznake merskih enot. V naslovih in izvle~ku naj ne bo kratic. Na mestu, kjer se kratica prvi~ pojavi v besedilu, naj bo izraz, ki ga nadome{~a, polno izpisan, v nadaljnjem besedilu uporabljano kratico navajajte v oklepaju. Uredni{ko delo Prispelo gradivo daje uredni{tvo v strokovno recenzijo in jezikovno lekturo. Po kon~anem uredni{kem delu vrnemo prispevek avtorju, da popravke odobri in upo{teva. Popravljeni ~istopis vrne v uredni{tvo. Med redakcijskim postopkom je zagotovljena tajnost vsebine prispevka. Avtor dobi v pogled tudi prve, t. i. krta~ne odtise, vendar na tej stopnji upo{tevamo samo {e popravke tiskovnih napak. Krta~ne odtise je treba vrniti v treh dneh, sicer menimo, da avtor nima pripomb. Za objavo prispevka prenese avtor avtorske pravice na In{titut za varovanje zdravja Republike Slovenije kot izdajatelja revije. Kr{enje avtorskih in drugih sorodnih pravic je kaznivo. Prispevkov ne honoriramo. Avtor dobi le izvod revije, v kateri je objavljen njegov ~lanek. Rokopisov, slik in disket ne vra~amo. INSTRUCTIONS TO THE AUTHORS OF THE SLOVENIAN JOURNAL OF PUBLIC HEALTH Instructions are in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Complete instructions are published in N Engl J Med 1997; 336: 309-15 and in Ann Intern Med 1997; 126: 36-47. Editorial board accepts only articles, that have not been and will not be published elsewhere. Parts of the article, summarized after other sources (especially illustrations and tables) should include the author’s and publisher’s permission to reproduct them in our Journal. If the contribution deals with experiments on humans it should be evident from the text that the experiments were in accordance with the ethical standards of the Helsinki-Tokio Declaration. When the work deals with experiments on animals it should be evident from the text that they were performed in accordance with the ethical principles. Authors whose submitted research work was performed with the support of a company, should indicate this in the accompanying letter. Manuscript Send the manuscripts to the editorial address: Zdravstveno varstvo, In{titut za varovanje zdravja, Trubarjeva 2, SI 1000 Ljubljana. Send 3 copies of typed or printed text with a copy in electronic form (on a disk) and original illustrations. Manuscripts should be written in Word for Windows word processor. Contribution should be typed or printed on white bond paper and double-spaced with margins of at least 25 mm. Scientific articles should be divided into following headings: Introduction, Methods, Results, Discussion and Conclusions. Other types of articles and review articles can be designed differently, but the division in headings and subheadings should be clearly evident from the size of characters in the titles. Headings and subheadings should be numbered decadally by standard SIST ISO 2145 and SIST ISO 690 (e. g. 1, 1.1, 1.1.1 etc.). Manuscript should be accompanied by an accompanying letter signed by all authors. It should include the statement that the article has not yet been published or sent for publication to some other journal (this is not required for abstracts and reports from professional meetings), and that the manuscript has been read and approved by all the authors. Name, address, telephone number and e-mail address of the responsible author, who will be responsible for communication with the editors and other authors should be cited. Title page The title page should carry the Slovene and English title of the article, which should be short and concise, descriptive and not affirmative (statements are not allowed in the title). Names of authors with concise academic and professional degrees and full address of the department, institution or clinic where the work has been performed should be cited. Authors be should qualified for authorship. They should contribute to the conception and design resp. analysis and interpretation of data, they should intelectualy draft resp. revise the article critically and approve the final version of the contribution. The collecting of data solely does not justify the authorship. Abstract and Key Words The second page should carry the abstract in Slovene and English. The abstract of the scientific article should be structured and of no more than 250 words, the abstracts of other articles should be unstructured and of no more than 150 words. The abstract should summarize the content and not only enumerate the essential parts of the work. Avoid abbreviations. Abstract should be written in third person. When the paper is written in English language, the abstract will be published in Slovene. The abstract of a scientific article should state the purpose of the investigation, basic procedures, main findings together with their statistical significance, and principal conclusions. 3 - 10 key words should be cited for the purpose of indexing. Terms from the MeSH - Medical Subject Headings listed in Index Medicus should be used. The abstract should normally be written in one paragraph, only exceptionally in several. The author should propose the cathegory of the article, but the final decision is adopted by the editor on the base of the suggestion of the professional reviewer. References Each mentioning of statements or findings by other authors should be supported by reference. References should be numbered consecutively in the same order in which they appear in the text. Reference should be cited at the end of the cited statement. References in text, illustrations and tables should be indicated by Arabic numerals in parentheses. References, cited only in tables or illustrations should be numbered in the same sequence as they will appear in the text. Avoid using abstracts and personal communications as references (the latter can be cited in the text). The list of the cited literature should be added at the end of the contribution. Literature should be cited according to the enclosed instructions that are in accordance with those used by U. S. National Library of Medicine in Index Medicus. The titles of journals should be abbreviated according to the style used in Index Medicus (complete list on the URL address:http://www.nlm.nih.gov). List the names of all authors, if there are six authors or more, list first six authors than add et al. Examples for literature citation: example for a book: 1. Premik M. Uvod v epidemiologijo. Ljubljana: Medicinska fakulteta, 1998. 2. Mahy BWJ. A dictionary of virology (2nd ed.). San Diego, Academic Press, 1997. example for the chapter in a book: 3. Urlep F. Razvoj osnovnega zdravstva v Sloveniji zadnjih 130 let. In: [vab I, Rotar-Pavli~ D, editors. Dru‘inska medicina, Ljubljana, Zdru‘enje zdravnikov dru‘inske medicine, 2002: 18-27. 4. Goldberg BW. Population-based health care. In: Taylor RB, editor. Family medicine. 5th ed. New York: Springer, 1999: 32-6. example for the article in a journal: 5. Barry HC, Hickner J, Ebell MH, Ettenhofer T. A randomized controlled trial of telephone management of suspected urinary tract infections in women. J Fam Pract 2001; 50: 589-94. example for the article in journal with no author given: 6. Anon. Early drinking said to increase alcoholism risk. Globe 1998; 2: 8-10. example for the article in journal with organization as author: 7. Women’s Concerns Study Group. Raising concerns about family history of breast cancer in primary care consultations: prospective, population based study. BMJ 2001; 322: 27-8. example for the article from journal volume with supplement, with number: 8. Shen HM, Zhang QF. Risk assessment of nickel carcinogenicity and occupational lung cancer. Environ Health Perspect 1994; 102 Suppl 2: 275-82. 9. Payne DK, Sullivan MD, Massie MJ. Women’s psychological reactions to breast cancer. Semin Oncol 1996; 23 (1 Suppl 2): 89-97. example for the article from collection of scientific papers: 10. Sugden K. et al. Suicides and non-suicidal deaths in Slovenia: Molecular genetic investigation. In: 9th European Symposium on Suicide and Suicidal Behaviour. Warwick : University of Oxford, 2002: 76. example for master theses, doctor theses and Pre{eren awards: 11. Bartol T. Vrednotenje biotehni{kih informacij o rastlinskih drogah v dostopnih virih v Sloveniji. Doktorska disertacija. Ljubljana, Biotehni{ka fakulteta, 1998. example for electronic sources: 12. Mendels P. Textbook publishers extend lessons online. Pridobljeno 23.9.1999 s spletne strani: http://www.nytimes.com/ library/tech/99/09. Tables Type or print on the place in the text where they belong. Tables should be composed by lines and columns which intersect in fields. Number tables consecutively. Each table should be cited in the text and supplied with a brief title. Explain all the abbreviations and non-standard units in the table. Illustrations Illustrations should be professionally drawn. When preparing the illustrations consider the black-and-white print. Illustration material should be prepared: • In black-and-white (not in color!); • Surfaces should have no tone-fills, hatchings should be chosen instead (in case of bar-charts, so called pie-charts or maps); • In linear graphs the individual lines sjould also be separated by various kinds of hatching or by different markers (triangles, asterisks…), but not by color; • Graphs should have white background (i. e. without background). Letters, numbers or symbols should be clear, even and of sufficient size to be still legible on a reduced illustration. Freehand or typewritten lettering in the illustration is unacceptable. Submit original drawings resp. photographs. You are requested not to scan the illustrations by yourself. On the back of the photograph the consecutive number of photograph, author’s name and the title of article should be written, and in unclear cases the top resp. the bottom should be indicated. Figures, drawn in computer programmes should be copied in original programme (software) on a disk. Photographs of X-ray films and slides should be provided by author himself. Each figure should be cited in the text. Accompanying text to the illustration should contain its title and the necessary explanation of its content. Illustration should be intelligible also without reading the article. All the abbreviations from the figure should be explained. The use of abbreviations in the accompanying text to the illustration is unacceptable. Accompanying texts to illustrations should be written in the place of their appearing in the text. If the identity of the patient can be recognized on the photograph, a written permission of the patient for its reproduction should be submitted. Units of Measurement Should be in accordance with International System of Units (SI). Abbreviations Avoid abbreviations, with the exception of internationally valid signs for units of measurement. Avoid abbreviations in the title and abstract. The full term for which an abbreviation stands should precede its first use in the text, abbreviation used in further text should be cited in parentheses. Editorial work The received material is submitted by the editorial board to professional reviewer and reader (language editor). After this editorial procedure, the contribution is sent to the author for approval and consideration of corrections. The final copy is than again submitted to the editorial board. During the editorial procedure, the secrecy of the contribution content is guaranteed. Author receives in consideration also the first print, but at this stage corrigenda (printing errors) only are to be considered. Proofreadings should be returned in three days, otherwise it is considered that the author has no remarks. When the manuscript is accepted for publication, the author assigns copyright ownership of the material to the Institute of Public Health of the Republic of Slovenia as the publisher. Any violation of the copyright will be legally persecuted. Contributions are not remunerated. The author receives one copy of the issue in which the article is published. Manuscripts, illustrations and disks will not be returned. BELEŽKE BELEŽKE BELEŽKE