In a pandemic situation, resources in intensive care units may be stretched to the breaking point, and critical care triage may become necessary. In such a situation, I argue that a patient's combined vulnerability to illness and social disadvantage should be a justification for giving that patient some priority for critical care. In this article I present an example of a critical care triage protocol that recognizes the moral relevance of vulnerability to illness and social disadvantage, from the Canadian province of Newfoundland and Labrador.
During the past century, long-term care in the United States has evolved through five cycles of development, each lasting approximately twenty years. Each, focusing on distinct concerns, produced unintended consequences. Each also added a layer to an accumulation of contradictory approaches--a patchwork system now pushed to the breaking point by increasing needs and financial pressures. Future policies must achieve a better synthesis of approaches inherited from the past, while addressing their unintended consequences. Foremost must be assuring access to essential care, delivery of high-quality services in an increasingly deinstitutionalized system, and a reduction in social and economic disparities.
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.
Cites: N Engl J Med. 1991 Oct 10;325(15):1072-71891009
This study assessed whether US and Canadian smoking reduction objectives for the year 2000 are attainable. The United States seeks to cut smoking in its population to 15%; the Canadian goal is 24%.
Smoking data were obtained for the United States (1974-1994) and Canada (1970-1995) for the overall populations and several age-sex subpopulations. Analyses estimated trends, future prevalences, and the likelihood of goal attainment. Structural time-series models were used because of their ability to fit a variety of trends.
The findings indicate that smoking has been declining steadily since the 1970s, by approximately 0.7 percentage points a year, in both countries. Extrapolating these trends to the year 2000, the US prevalence will be 21% and the Canadian prevalence 24%.
If the current trends continue, the Canadian goal seems attainable, but the US goal does not. The US goal is reachable only for 65-to 80-year-olds, who already have low smoking prevalences. It appears that both countries must increase their commitment to population-based tobacco control.
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The concept of self-care is multidimensional, with many defining elements. This paper describes the origin of this comprehensive concept. It examines the response of the nursing discipline to citizen self-care initiatives and the subsequent effects this response has had on the development of nursing knowledge. The evolution of self-care as a core concept within Canadian health policy is presented; the potential readiness fo citizens to accept self-care as an aspect of healthcare delivery is explored, identifying potential benefits and obstacles. The paper concludes with a proposed self-care approach to healthcare reform in Canada and the subsequent influence this approach may have on the discipline of nursing. The congruency between a self-care healthcare delivery system and the theoretical foundations and perspective of healthcare delivery held by the nursing discipline is discussed. The role nurses might assume in shaping a self-care healthcare delivery system is delineated.
Associations between pedagogues attitudes, praxis and policy in relation to physical activity of children in kindergarten--results from a cross sectional study of health behaviour amongst Danish pre-school children.
This paper reports on associations between physical activity, pedagogue's attitudes towards promoting physical activity and the physical activity policies (PAP) in kindergarten. The paper deals with data on physical activity of 3-6 year olds in kindergarten which originates from a cross-sectional study conducted in 2006 among all Danish kindergartens. A questionnaire of 48 questions based on pedagogues assessment regarding the health related polcies and praxis in kindergarten and the attitudes of pedagogues was mailed (n = 4200) to all institutions in the country. In total, 1149 kindergartens and 693 integrated institutions returned the survey. The results show a relation between pedagogue's attitudes towards promoting children's physical activity and the number of children having moderately intense physical activity for at least one hour a day. The study also shows a positive association between policies and pedagogue's attitudes towards promoting children's physical activity and the number of days that pedagogues initiated games that made the children physically active. The study suggests that the social and organizational environment in the kindergarten is an important determinant for the level of physical activity among children. This means that the individual norms and attitudes of pedagogues along with the collective intentions and values expressed in written and adopted organizational policies (a Physical Activity Policy--PAP) are important aspects to be worked upon if kindergarten should play an active role in the promotion of healthy lifestyle among kindergarten aged children. Strong municipal and institutional leadership as well as educational interventions in the curricula of pedagogues could be important ways to bring about such change.
In the late seventies the World Health Organization developed a strategy of Health for all towards year 2000, to which Norwegian health authorities have consented. This article presents and discusses the sub-goals for expectation of life and mortality, and analyzes the possibilities of reaching them. The desired reduction of at least 25% in accident mortality rates and cardiovascular mortality rates in relation to the reference period 1976-80 will probably be reached. In addition, the desired 15% reduction in cancer mortality is likely to be reached for persons under 40 years of age. Infant mortality does not appear to be declining, cancer mortality for people over 40 years of age is increasing, and the suicidal and homicidal rates are increasing faster than any other cause of death. The possibilities of reversing this development require a structured plan and comprehensive changes in the way society is organized, with more emphasis on care, social network planning and reduction of the multicausal risk load that modern life implies. Some of the sub-goals are not sufficiently founded on accessible information, and should be revised.