The 1984 Canada Health Act (CHA) is the major piece of Federal legislation that governs health care accessibility in the provinces and territories. According to the CHA, all provinces and territories in Canada must uphold five principles in order to receive federal funding for health care (universality, comprehensiveness, portability, public administration, and accessibility). In Canada, there are competing views among policy makers and consumers about how the CHA's principle of accessibility should be defined, interpreted and used in delivering health care. During the 1990s, the health care perceptions of Canadians and their health care behaviours were measured through both public opinion polls and Statistics Canada's National Population Health Survey (NPHS). The goal of this paper is to examine perceptions of accessibility in public opinion polls and actual accessibility as measured through the NPHS. Public opinion polls demonstrate that while Canadians want to preserve the principles of the CHA, a majority of Canadians are losing confidence in their health care system. In contrast, the results from the NPHS reveal that only 6% of Canadians aged 25 years and older have experienced accessibility problems. Among those who report access problems, the barriers to accessibility are linked to specific socio-economic, socio-demographic and health characteristics of individuals. We discuss these findings in the context of the current debates surrounding accessibility within the CHA and the Canadian health care system.
Given the cutbacks which have been carried out in the Swedish welfare state despite the unchanged official policy of allocation of home help services according to needs, it is essential to evaluate the factors which guide the allocation of home help today. Whereas numerous studies have identified factors which predict entry into the home help system, the present paper concentrates on predictors of the amount of home help amongst those allocated assistance. Data were obtained from the population-based care and services section of the 2002 Swedish National Study of Aging and Care-Kungsholmen (SNAC-K). All home help recipients (> or = 65 years of age) living in an inner city district of Stockholm (Kungsholmen) were analysed with ordinary least squares regressions to identify predictors of the number of hours of home help (n = 943). Need indicators, i.e. dependency in activities of daily living (ADLs) and instrumental ADLs (IADLs), and cognitive impairment (Berger scale) were the strongest predictors of more hours of home help. The addition of sociodemographic (i.e. age, gender and income), environmental (i.e. informal care, housing adaptations and housing accessibility) and structural (i.e. variations in allocation decisions between one care manager and another) factors contributed only marginally to the explained variance. Hours of help entitlement increased slightly with greater age. Co-residing individuals were allocated significantly fewer home help hours than those living alone. Income and regular access to informal care were not significant predictors. The fact that services are provided according to need criteria does not necessarily mean that the provided services are adequate to meet needs. On the macro level, social policy decisions and available economic and manpower resources determine the allotment of municipal home help. However, this study in an urban sample suggests that, within the available resources, the amount of home help allocated is guided mainly by need indicators amongst those given assistance.
Although canadian seniors enjoy economic security and good health and have made substantial gains in recent decades, this well-being is not equally shared among socioeconomic groups and between men and women. As for younger age groups, income predicts health status in later life, but less powerfully. Potential alternative explanations include an overriding influence of the aging process, the subjective effects of income loss at retirement and the attenuation of the poverty gap owing to public retirement income. Older women are more likely to age in poverty than men, to live alone and to depend on inadequately resourced chronic health care and social services. These differences will hold as well for the next cohort of seniors in Canada. Addressing these disparities in health requires a comprehensive, multisectoral approach to health that is embodied in Canada's population health model. Application of this model to reduce these disparities is described, drawing upon the key strategies of the population health approach, recent federal government initiatives and actions recommended to the government by federal commissions.
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St (Ste 3030), Boston, MA 02120, USA. firstname.lastname@example.org
To evaluate the effects of patient copayment and coinsurance policies on adherence to therapy with beta-adrenergic blocking agents (beta-blockers) and on the rate of initiation of beta-blocker therapy after acute myocardial infarction (MI) in a population-based natural experiment.
Three sequential cohorts included British Columbia residents age 66 years and older who initiated beta-blocker therapy during time intervals with full drug coverage (2001), a $10 or $25 copayment (2002), and 25% coinsurance (2003-2004). We used linked data on all prescription drug dispensings, physician services, and hospitalizations. Follow-up of each cohort was 9 months after the policy changes.
We measured the proportion of subjects in each cohort who were adherent to beta-blocker therapy over time, with adherence defined as having >80% of days covered. We also measured the proportion of patients initiating beta-blocker therapy after acute MI. Policy effects were evaluated using multivariable regression.
Adherence to beta-blocker therapy was marginally reduced as a consequence of the copayment policy (-1.3 percentage points, 95% confidence interval [CI] = -2.5 , -0.04) or the coinsurance policy (-0.8 percentage points, 95% CI = -2.0, 0.3). The proportion of patients initiating beta-blockers after hospitalization for acute MI remained steady at about 61% during the study period, similar to that observed in a control population of elderly Pennsylvania residents with full drug coverage.
Fixed patient copayment and coinsurance policies had little negative effect on adherence to relatively inexpensive beta-blocker therapy, or initiation of beta-blockers after acute MI.
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We examined how adult children in Canada whose parents were hospitalized in an acute care setting perceived responsibility for their parents' care. Using a visual analogue scale, adult children rated the amount of financial, emotional, and physical support families "should" and "could" give to elderly persons described in four vignettes. All scores were high, with "should" consistently higher than "could" for every vignette and for each of the three types of support. For daughters, the more aggressive the parent, the lower the "should" score for financial support. The same relationship was observed for incontinence and these findings were consistent over all four vignettes.
Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups.
To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation.
Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events.
A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients.
Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction.
After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits.
In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.
Comment In: JAMA. 2001 May 9;285(18):2328-911343477
Limited information is available on the effect of age on stroke management and care delivery. Our aim was to determine whether access to stroke care, delivery of health services, and clinical outcomes after stroke are affected by age.
This was a prospective cohort study of patients with acute ischemic stroke in the province of Ontario, Canada, admitted to stroke centers participating in the Registry of the Canadian Stroke Network between July 1, 2003 and March 31, 2005. Primary outcomes were the following selected indicators of quality stroke care: (1) use of thrombolysis; (2) dysphagia screening; (3) admission to a stroke unit; (4) carotid imaging; (5) antithrombotic therapy; and (6) warfarin for atrial fibrillation at discharge. Secondary outcomes were risk-adjusted stroke fatality, discharge disposition, pneumonia, and length of hospital stay.
Among 3631 patients with ischemic stroke, 1219 (33.6%) were older than 80 years. There were no significant differences in stroke care delivery by age group. Stroke fatality increased with age, with a 30-day risk adjusted fatality of 7.1%, 6.5%, 8.8%, and 14.8% for those aged 59 or younger, 60 to 69, 70 to 79, and 80 years or older, respectively. Those aged older than 80 years had a longer length of hospitalization, increased risk of pneumonia, and higher disability at discharge compared to those younger than 80. This group was also less likely to be discharged home.
In the context of a province-wide coordinated stroke care system, stroke care delivery was similar across all age groups with the exception of slightly lower rates of investigations in the very elderly. Increasing age was associated with stroke severity and stroke case-fatality.
To analyze the regular dental care behavior and prevalence of edentulism in adult Danes, reported in sequential cross-sectional oral health surveys by the application of a marginal approach to consider the possible clustering effect of birth cohorts.
Data from four sequential cross-sectional surveys of non-institutionalized Danes conducted from 1975-2005 comprising 4330 respondents aged 15+ years in 9 birth cohorts were analyzed. The key study variables were seeking dental care on an annual basis (ADC) and edentulism. For the analysis of ADC, survey year, age, gender, socio-economic status (SES) group, denture-wearing, and school dental care (SDC) during childhood were considered. For the analysis of edentulism, only respondents aged 35+ years were included. Survey year, age, gender, SES group, ADC, and SDC during childhood were considered as the independent factors. To take into account the clustering effect of birth cohorts, marginal logistic regressions with an independent correlation structure in generalized estimating equations (GEE) were carried out, with PROC GENMOD in SAS software.
The overall proportion of people seeking ADC increased from 58.8% in 1975 to 86.7% in 2005, while for respondents aged 35 years or older, the overall prevalence of edentulism (35+ years) decreased from 36.4% in 1975 to 5.0% in 2005. Females, respondents in the higher SES group, in more recent survey years, with no denture, and receiving SDC in all grades during childhood were associated with higher probability of seeking ADC regularly (P
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