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A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience.Family Practice Jul 2018Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness...
OBJECTIVE
Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period.
METHODS
Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported.
RESULTS
Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition.
CONCLUSIONS
In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.
Topics: Adult; Delivery of Health Care, Integrated; Family Practice; Health Care Reform; Humans; Preventive Health Services; Primary Health Care; Quality Indicators, Health Care; Taiwan
PubMed: 29194539
DOI: 10.1093/fampra/cmx111 -
The Cochrane Database of Systematic... Dec 2018Early accurate detection of all skin cancer types is essential to guide appropriate management, reduce morbidity and improve survival. Basal cell carcinoma (BCC) is... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early accurate detection of all skin cancer types is essential to guide appropriate management, reduce morbidity and improve survival. Basal cell carcinoma (BCC) is usually localised to the skin but has potential to infiltrate and damage surrounding tissue, while cutaneous squamous cell carcinoma (cSCC) and melanoma have a much higher potential to metastasise and ultimately lead to death. Exfoliative cytology is a non-invasive test that uses the Tzanck smear technique to identify disease by examining the structure of cells obtained from scraped samples. This simple procedure is a less invasive diagnostic test than a skin biopsy, and for BCC it has the potential to provide an immediate diagnosis that avoids an additional clinic visit to receive skin biopsy results. This may benefit patients scheduled for either Mohs micrographic surgery or non-surgical treatments such as radiotherapy. A cytology scrape can never give the same information as a skin biopsy, however, so it is important to better understand in which skin cancer situations it may be helpful.
OBJECTIVES
To determine the diagnostic accuracy of exfoliative cytology for detecting basal cell carcinoma (BCC) in adults, and to compare its accuracy with that of standard diagnostic practice (visual inspection with or without dermoscopy). Secondary objectives were: to determine the diagnostic accuracy of exfoliative cytology for detecting cSCC, invasive melanoma and atypical intraepidermal melanocytic variants, and any other skin cancer; and for each of these secondary conditions to compare the accuracy of exfoliative cytology with visual inspection with or without dermoscopy in direct test comparisons; and to determine the effect of observer experience.
SEARCH METHODS
We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We also studied the reference lists of published systematic review articles.
SELECTION CRITERIA
Studies evaluating exfoliative cytology in adults with lesions suspicious for BCC, cSCC or melanoma, compared with a reference standard of histological confirmation.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). Where possible we estimated summary sensitivities and specificities using the bivariate hierarchical model.
MAIN RESULTS
We synthesised the results of nine studies contributing a total of 1655 lesions to our analysis, including 1120 BCCs (14 datasets), 41 cSCCs (amongst 401 lesions in 2 datasets), and 10 melanomas (amongst 200 lesions in 1 dataset). Three of these datasets (one each for BCC, melanoma and any malignant condition) were derived from one study that also performed a direct comparison with dermoscopy. Studies were of moderate to poor quality, providing inadequate descriptions of participant selection, thresholds used to make cytological and histological diagnoses, and blinding. Reporting of participants' prior referral pathways was particularly poor, as were descriptions of the cytodiagnostic criteria used to make diagnoses. No studies evaluated the use of exfoliative cytology as a primary diagnostic test for detecting BCC or other skin cancers in lesions suspicious for skin cancer. Pooled data from seven studies using standard cytomorphological criteria (but various stain methods) to detect BCC in participants with a high clinical suspicion of BCC estimated the sensitivity and specificity of exfoliative cytology as 97.5% (95% CI 94.5% to 98.9%) and 90.1% (95% CI 81.1% to 95.1%). respectively. When applied to a hypothetical population of 1000 clinically suspected BCC lesions with a median observed BCC prevalence of 86%, exfoliative cytology would miss 21 BCCs and would lead to 14 false positive diagnoses of BCC. No false positive cases were histologically confirmed to be melanoma. Insufficient data are available to make summary statements regarding the accuracy of exfoliative cytology to detect melanoma or cSCC, or its accuracy compared to dermoscopy.
AUTHORS' CONCLUSIONS
The utility of exfoliative cytology for the primary diagnosis of skin cancer is unknown, as all included studies focused on the use of this technique for confirming strongly suspected clinical diagnoses. For the confirmation of BCC in lesions with a high clinical suspicion, there is evidence of high sensitivity and specificity. Since decisions to treat low-risk BCCs are unlikely in practice to require diagnostic confirmation given that clinical suspicion is already high, exfoliative cytology might be most useful for cases of BCC where the treatments being contemplated require a tissue diagnosis (e.g. radiotherapy). The small number of included studies, poor reporting and varying methodological quality prevent us from drawing strong conclusions to guide clinical practice. Despite insufficient data on the use of cytology for cSCC or melanoma, it is unlikely that cytology would be useful in these scenarios since preservation of the architecture of the whole lesion that would be available from a biopsy provides crucial diagnostic information. Given the paucity of good quality data, appropriately designed prospective comparative studies may be required to evaluate both the diagnostic value of exfoliative cytology by comparison to dermoscopy, and its confirmatory value in adequately reported populations with a high probability of BCC scheduled for further treatment requiring a tissue diagnosis.
Topics: Adult; Azure Stains; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Coloring Agents; Cytodiagnosis; Dermoscopy; Humans; Melanoma; Papanicolaou Test; Sensitivity and Specificity; Skin Neoplasms; Melanoma, Cutaneous Malignant
PubMed: 30521689
DOI: 10.1002/14651858.CD013187 -
Preventive Medicine Jun 2018Cervical cancer is the fourth most common cancer in women worldwide. Screening can reduce both the incidence and mortality of the disease but is often not utilized by...
Cervical cancer is the fourth most common cancer in women worldwide. Screening can reduce both the incidence and mortality of the disease but is often not utilized by lower socioeconomic groups. A systematic review, including studies of interventions to improve breast and cervical cancer screening uptake, up to 2006, found targeted interventions could be effective. A formal update has been conducted on the effectiveness of interventions to improve the uptake of cervical cancer screening among lower socioeconomic groups. A systematic computerized literature search was undertaken in June 2016 for relevant papers published since 2006. Data was extracted on study participants, setting, intervention and control using a predefined extraction tool and a full quality assessment was undertaken using the Cochrane risk of bias tool. This update yielded 16 studies of mixed quality, in addition to the 13 studies from the original review. The interventions were categorized into local interventions including HPV self-testing, lay health advisors, inreach, outreach and mixed, and strategies enhancing attendance within an organized program. This review has found two large, randomized controlled trials for the use of HPV self-testing to increase cervical screening uptake. Both reviews have found varying success using lay health advisors, with the majority of included papers reporting a statistically significant increase in screening uptake. HPV self-testing can improve uptake of cervical cancer screening among lower socioeconomic groups. This is a relatively new method of cervical screening that was not included in the earlier review. The findings of this updated review largely support that of the 2006 review for the use of lay health advisors.
Topics: Early Detection of Cancer; Female; Healthcare Disparities; Humans; Mass Screening; Socioeconomic Factors; Uterine Cervical Neoplasms
PubMed: 29203349
DOI: 10.1016/j.ypmed.2017.11.019 -
International Journal of STD & AIDS Nov 2019
Meta-Analysis
Topics: Adult; Aged; Cervix Uteri; Condylomata Acuminata; Female; Humans; Middle Aged; Papanicolaou Test; Papillomaviridae; Papillomavirus Infections; Papillomavirus Vaccines; Uterine Cervical Diseases; Uterine Cervical Neoplasms; Vaginal Smears
PubMed: 31640474
DOI: 10.1177/0956462418824441 -
Diagnostic Cytopathology Apr 2019Anal intraepithelial neoplasia (AIN) refers to a precancerous lesion of anal squamous cell carcinoma (SCC). Human papillomavirus (HPV) is considered a crucial risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Anal intraepithelial neoplasia (AIN) refers to a precancerous lesion of anal squamous cell carcinoma (SCC). Human papillomavirus (HPV) is considered a crucial risk factor for AIN. Individuals with high-risk sexual behaviour, such as receptive anal intercourse and multiple sexual partners, as well as men who have sex with men exhibit a relatively high rate of AIN. The anal cytology is a screening method for AIN in high-risk individuals, and patients with abnormal anal cytology may benefit from high-resolution anoscopy. This study explored the predictive value of the anal cytology for the detection of AIN or worse (AIN+).
METHODS
We searched the databases of PubMed, BioMed Central, Cochrane Library, and Google Scholar for relevant studies. Studies on the diagnostic efficacy of the anal cytology for predicting anal cancer on a per-patient basis were included. We excluded review articles. Either prospective trials or retrospective studies were included. We performed the meta-analysis by using a random-effects model to generate a pooled sensitivity, specificity, and diagnostic odds ratio (DOR). All analyses were performed using the MetaDiSc version 1.4 software (Universidad Complutense, Madrid, Spain).
RESULTS
Twelve studies with 2541 participants were retrieved. The meta-analysis of the studies assessing the predictive value of the anal cytology for detecting AIN+ generated a pooled sensitivity of 0.79 (95% confidence interval [CI], 0.77-0.82) and a pooled specificity of 0.66 (95% CI, 0.64-0.69). The pooled DOR for the anal cytology was 5.31 (95% CI, 3.31-8.49).
CONCLUSIONS
Our results revealed that the anal cytology might be effective in diagnosing AIN+.
Topics: Anus Neoplasms; Carcinoma in Situ; Female; Humans; Male; Papanicolaou Test; Papillomavirus Infections; Predictive Value of Tests
PubMed: 30605263
DOI: 10.1002/dc.24078