The Indian Health Service (IHS) is unique among U.S. private and public health programs in that free comprehensive health services are provided to eligible American Indians and Alaska Natives regardless of their ability to pay. However, resource limitations may compel some eligible persons to go outside of the IHS system to receive health care. Although IHS eligibles have comparatively low rates of private or public health care coverage, and much of this population lives in underserved areas, over half of IHS-eligible persons had some type of out-of-plan use in 1987. Furthermore, services received through private providers appear to supplement those received through IHS-sponsored providers. Overall, persons who use both IHS and non-IHS providers have higher levels of health care use than do those who rely exclusively on the IHS.
To assess the current practice patterns of liver transplant centres in Canada and the USA regarding transplant eligibility.
Liver transplantation is an evolving field and today remains the only life-sustaining treatment for end-stage liver disease. Issues of allocation and transplant eligibility are important factors in the ethical practice of medicine.
Questionnaires were mailed to liver transplant programme directors in Canada and the USA inquiring about current practices regarding recipient eligibility.
This study demonstrates that there is consensus in the use of other eligibility criteria, including non-compliance, social status, abstinence from alcohol and methadone and cocaine use. Interestingly, literature is lacking to support the use of these parameters as eligibility criteria with the exception of alcohol. There is a lack in consensus regarding marijuana use, human immunodeficiency virus status, ability to accept blood transfusions and prisoner status. The literature suggests that liver transplantation in select patients who refuse blood transfusions results in good outcomes.
Important decisions regarding transplant eligibility still have to be made empirically in the absence of scientific literature about various social issues. While consensus among transplant programmes is useful, it is important that we continue to use the evidence in the literature to revise these eligibility criteria, keeping in mind ethical principles applied to the access and allocation of a scarce resource.
To determine inter- and intraobserver agreement among Canadian retina specialists in their angiographic classification of choroidal neovascularization and their decision to treat with photodynamic therapy. Agreement was also determined between retina specialists and a Reading Center.
Forty retina specialists graded 24 cases of exudative age-related macular degeneration on two occasions separated by 6 months. Participants were asked to categorize the choroidal neovascularization and indicate if they would treat with photodynamic therapy. Agreement was determined for decision to treat and for interpretation of the fluorescein angiogram. Angiographic interpretation by participants was compared with that of the Reading Center.
The kappas among the 40 participants for lesion categorization and treatment decision were 0.43 (95% confidence interval: 0.36-0.52) and 0.29 (95% confidence interval: 0.18-0.42), respectively. The kappa for intraobserver agreement was 0.57 (95% confidence interval: 0.50-0.64) for lesion categorization and 0.58 (95% confidence interval: 0.43-0.74) for treatment decision. The mean percent agreement with the Reading Center for lesion categorization was 65.4%.
There was moderate interobserver agreement for choroidal neovascularization categorization and poor agreement among Canadian retina specialists for decision to treat with photodynamic therapy. There was moderate intraobserver agreement for both treatment decision and lesion categorization. There was moderate agreement between observers and the Reading Center for angiographic choroidal neovascularization categorization.
Most Canadians die in inpatient settings. Our aim was to determine the availability of medical services, programs, and care for common palliative procedures, in hospices, palliative care units (PCUs), and hospital medical wards (MWs) providing inpatient palliative care in Ontario, Canada.
We identified facilities providing inpatient palliative care using the Ontario Hospital Association (OHA) and Hospice Association of Ontario (HAO) websites. An electronic survey was sent to the person responsible for palliative care at each facility. We compared services available among the three types of units, using Fisher's exact and Kruskal-Wallis tests.
Of 128 surveys sent, 102 (80%) were completed and returned, from 58 MWs, 31 PCUs, and 13 hospices. MWs were the most common location of palliative care overall, particularly in rural areas. PCUs were most likely to provide care for common procedures (e.g., tracheostomy, nephrostomy; p
Cardiac resynchronization therapy (CRT) and primary prophylactic implantable cardioverter-defibrillators (ICDs) are underutilized in heart failure (HF). This may originate from an unawareness of device benefits and indications among physicians responsible for HF care and referral. We aimed to describe the awareness of indications for device therapy in a generalized sample of Swedish physicians.
A randomly selected sample of Swedish physicians specializing in cardiology, internal medicine, and family medicine and interns (5% of eligible physicians, n = 519) was invited to fill in a 23-item survey, testing their awareness of indications for device therapy and, as comparison, pharmacological therapy. Acceptable awareness (AA) of CRT indication was predefined as recognizing that a left bundle branch block on ECG warrants further evaluation for CRT. Acceptable awareness of ICD indication was predefined as recognizing that ejection fraction =35% alone, without a history of ventricular tachycardia, is sufficient to warrant a primary prophylactic ICD. The response rate was 37% (n = 168). Overall, 32% met AA of CRT indication, and significantly less (15%) met AA of ICD indication. Specialist certification in cardiology was the only significant predictor for AA [odds ratio (95% confidence interval): 37 (10-138)]. However, even among cardiologists, awareness of ICD indications was low (61% with AA). Guideline-recommended indications for pharmacological therapy were conceived significantly better (P = 0.02) than device therapy [median (interquartile range) of correct answers: 50% (33-50) compared with 36% (14-57)].
The study identified an important and substantial awareness gap in the medical community that may explain some of the previously reported low referral rates and utilization of device therapy in HF.
Nutrition North Canada (NNC) is a retail subsidy program implemented in 2012 and designed to reduce the cost of nutritious food for residents living in Canada's remote, northern communities. The present study evaluates the extent to which NNC provides access to perishable, nutritious food for residents of remote northern communities.
Program documents, including fiscal and food cost reports for the period 2011-2015, retailer compliance reports, audits of the program, and the program's performance measurement strategy are examined for evidence that the subsidy is meeting its objectives in a manner both comprehensive and equitable across regions and communities.
NNC lacks price caps or other means of ensuring food is affordable and equitably priced in communities. Gaps in food cost reporting constrain the program's accountability. From 2011-15, no adjustments were made to community eligibility, subsidy rates, or the list of eligible foods in response to information provided by community members, critics, the Auditor General of Canada, and the program's own Advisory Board. Measures to increase program accountability, such as increasing subsidy information on point-of-sale receipts, make NNC more visible but do nothing to address underlying accountability issues Conclusions: The current structure and regulatory framework of NNC are insufficient to ensure the program meets its goal. Both the volume and cost of nutritious food delivered to communities is highly variable and dependent on factors such as retailers' pricing practices, over which the program has no control. It may be necessary to consider alternative forms of policy in order to produce sustainable improvements to food security in remote, northern communities.
Cites: Int J Circumpolar Health. 2016 Jul 05;75:31127 PMID 27388896