A large number of people all over the world suffer from skin conditions. Dermatological problems comprise about 10 % of a general practitioner's caseload and probably more for pharmacists. The literature furthermore emphasises that skin diseases are becoming a significant problem in the developing world. There is a need to establish an effective method to achieve good health and quality of life for patients with dermatological problems. The general objective of this study was to investigate the usage patterns and cost of dermatological products in the private health care sector of South Africa by using a medicine claims database. The focus was specifically on dermatological products with a prevalence of more than 10 % in the database. A quantitative retrospective drug utilisation research design was used to evaluate the usage patterns and costs of dermatological products in three four-monthly intervals of 2001 and 2004. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The dermatological product groups for this study were antibacterial and antifungal drugs, corticosteroids and anti-acne products and were analysed according to the MIMS classification. Of all analysed prescriptions issued only 8.57 % (n = 126 447) during 2001 (N = 1 475 380) and 6.82 % (n = 177 122) during 2004 (N = 2 595 254) consisted of dermatological products. Of the total number of products prescribed, the dermatological products constituted 4.77 %I (n = 140 701) for 2001 (N = 2 95 1 326) and 3.77 % (n = 199 976) for 2004 (N = 5 305 882). The total cost of the dermatological products was 4.98 % (n = R18 913 889.92) of the total cost of all medicine products during 200 1 (N = R379 708 489). During 2004 (N = R66 1 223 146) the total cost of dermatological products was 4.09 % (n = R27 025 540.48) of the total cost of all medicine products in the database. The cost-prevalence index for 2001 and 2004 respectively showed that the dermatological products were relatively expensive with values of 1.03 and 1.09. The antibacterial and antifungal drugs, corticosteroids and anti-acne products represented 91.92 % (n = 129 336) and 87.97 % (n = 175 9 16) of all dermatological products during 2001 (N = 140 701) and 2004 (N = 199 976), respectively. These dermatological groups named above represented 91.57 % (n = R17 319 645.61) and 85.85 '% (n = R23 200 594.71), respectively, of the total cost of dermatological products during 200 1 (N = R18 9 13 889.92) and 2004 (N = R27 025 540.48). It was further found that the majority of dermatological products prescribed during the research periods was innovator products. The prevalence of innovator products for 2001 was 86.17 % (n = 12 1 249) with a total cost representing 94.16 % (n = R17 809 603.12). For 2004 the prevalence was 82.33 % (n = 164 640) with a total cost representing 91 .O1 '% (n = R24 594 923.72) of all the dermatological products prescribed. The number of innovator and generic products claimed during 2001 amounted to 86.17 % (n = 12 1 249) and 13.83 % (n = 19 452) respectively of the total number of products claimed (N = 140 701). During 2004 the number of innovator and generic products represented respectively 82.33 % (n = 164 640) and 17.67 O/o (n = 35 336) of the total number of products claimed (N = 199 976). The prevalence in the use of the dermatological products during 2004 increased with 55.25 % from January to April versus September to December. The cost-prevalence index indicated that the dermatological products were relatively expensive during January to August 2004. During September to December 2004 the cost-prevalence decreased and indicated that dermatological products became inexpensive. The average cost of dermatological products during the 2004 study period showed that the cost decreased. January to April (before implementation of the new single exit price structure) was compared to September to December (after implementation of the new single exit price structure). This comparison indicated that the average cost decreased by 22.88 %. It can be summarised that the average cost in the last study period decreased due to the changed price structure. The innovator products' prevalence was high and therefore more generics are needed in dermatology. If more generics are used the total cost of dermatological products might also decrease. The number of dermatological prescriptions increased towards 2004, but this may be because of more members or more medical aids claiming through this database. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2006.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Thesis--Lyon. / Label mounted on cover: "Diffusion: Librairie Klincksieck ... Paris."

Thèses (M.Sc.)--Université de Sherbrooke (Canada), 2001. / Titre de l'écran-titre (visionné le 20 juin 2006). Publié aussi en version papier.

Thèses (M.Sc.)--Université de Sherbrooke (Canada), 2003. / Titre de l'écran-titre (visionné le 20 juin 2006). Publié aussi en version papier.

Thèses (M.Sc.)--Université de Sherbrooke (Canada), 2007. / Titre de l'écran-titre (visionné le 20 juin 2008). In ProQuest dissertations and theses. Publié aussi en version papier.

Th. Sc. soc.--Grenoble, 1981.

Thèse--Histoire--Rennes 2. / Bibliogr. p. 621-639. Index.

Th. doct.--Méthodes physiques en télédétection--Paris 7, 1994. / En appendice, choix de documents en français et en anglais. 1995 d'après la déclaration de dépôt légal. Bibliogr. p. 117-123. Résumé en français et en anglais.

Thesis--Lyon. / Label mounted on cover: "Diffusion: Librairie Klincksieck ... Paris."