The proportion of older persons is increasing in developed and developing countries: this aging trend can be viewed as a two-edged sword. On the one hand, it represents remarkable successes regarding advances in health care; and on the other hand, it represents a considerable challenge for health systems to meet growing demand. A growing disequilibrium between supply and demand may be particularly challenging within publicly funding health systems that 'guarantee' services to eligible populations. Rehabilitation, including physical therapy, is a service that if provided in a timely manner, can maximize function and mobility for older persons, which may in turn optimize efficiency and effectiveness of overall health care systems. However, physical therapy services are not considered an insured service under the legislative framework of the Canadian health system, and as such, a complex public/private mix of funding and delivery has emerged. In this article, we explore the consequences of a public/private mix of physical therapy on timely access to services, and use the World Health Organization (WHO) health system performance framework to assess the extent to which the emerging system influences the goal of aggregated and equitable health. Overall, we argue that a shift to a public/private mix may not have positive influences at the population level, and that innovative approaches to deliver services would be desirable to strengthening rather than weaken the publicly funded system. We signal that strategies aimed at scaling up rehabilitation interventions are required in order to improve health outcomes in an evolving global aging society.
To describe the substantive and procedural criteria used for placing patients on the waiting list for liver transplantation and for allocating available livers to patients on the waiting list; to identify principal decision-makers and the main factors limiting liver transplantation in Canada; and to examine how closely cadaveric liver allocation resembles theoretic models of source allocation.
Medical directors of all seven Canadian adult liver transplantation centres, or their designates. Six of the questionnaires were completed.
Relative importance of substantive and procedural criteria used to place patients in the waiting list for liver transplantation and to allocate available livers. Identification of principal decision-makers and main limiting factors to adult liver transplantation.
Alcoholism, drug addiction, HIV positivity, primary liver cancer, noncompliance and hepatitis B were the most important criteria that had a negative influence on decisions to place patients on the waiting list for liver transplantation. Severity of disease and urgency were the most important criteria used for selecting patients on the waiting list for transplantation. Criteria that were inconsistent across the centres included social support (for deciding who is placed on the waiting list) and length of time on the waiting list (for deciding who is selected from the list). Although a variety of people were reported as being involved in these decisions, virtually all were reported to be health to be health care professionals. Thirty-seven patients died while waiting for liver transplantation in 1991; the scarcity of cadaveric livers was the main limiting factor.
Criteria for resource allocation decisions regarding liver transplantation are generally consistent among the centres across Canada, although some important inconsistencies remain. Because patients die while on the waiting list and because the primary limiting factor is organ supply, increased organ acquisition efforts are needed.
Access to health care services in Canada has been identified as an urgent priority, and chronic disease has been suggested as the most pressing health concern facing Canadians. Access to services for Canadians living with chronic disease, however, has received little emphasis in the research literature or in health policy reform documents. A systematic review of research into factors impeding or facilitating access to formal health services for people in Canada living with chronic illness is presented. The review includes 31 studies of Canadian populations published between 1990 and 2002; main results were analyzed for facilitators and barriers to access for people experiencing chronic disease. An underlying organizing construct of symmetry between consumers, providers, and the larger Canadian system is suggested as a relevant lens from which to view the findings. Finally, a discussion of the relationship between identified factors and the principles of primary health care is offered.
What determines access to the Voksentoppen Children's Asthma and Allergy Centre, the most specialized health care facility for asthmatic children in Norway? This publicly funded national institution is mandated to serve all segments of the population equally. The paper reports from the experiences of families with children having a confirmed diagnosis of moderate to severe asthma. The study population was selected from a national register of state cash-benefit recipients. Within this register, all families with a child under the age of 9 and with the diagnosis of asthma at the end of 1997 were selected (N = 2564). Further information about the population was gathered in a postal survey. It was found that access to the facility, measured as at least one admission during the period of the disease, was primarily determined by variations in morbidity. In particular, measures of health condition that presupposed a professional's evaluation of the child's health condition were significant. In addition, access was influenced by several factors not directly related to the need for treatment. Notably, children from families in which parents had a graduate education were over-represented among those with access to the top level of the institution's medical hierarchy. Multivariate analysis was used to search for causal mechanisms. It was found that families with a doctor in their social network had greater likelihood of access, and this in part accounted for the observed association between education and access. The pattern of access was also influenced by geographical factors, but not in a way that reduced the significance of educational background. Membership of, and participation in, patient organizations also increased the families' chances of receiving top-level professional treatment. The results depart from professional norms and officially stated health policy in Norway, which assert that health condition is the only valid criterion for allocating scarce medical goods.
To address concerns about disruptions in the continuity of health care delivered to residents in three remote aboriginal communities in northern Ontario, Canada, the local health authority initiated a study in collaboration with the department of Health Canada responsible for ensuring that aboriginal reserves receive mandatory health services, and an inter-disciplinary team of researchers from two universities. The study focussed on the delivery of oncology, diabetes and mental health care, specifically, as well as systems issues such as recruitment and retention of health human resources and financial costs. The paper discusses the procedures involved, the benefits derived and the challenges encountered in doing this as a community driven participatory action research project. It also summarizes the findings that led to community formulated policy and program recommendations.
Flight nurses in the Norwegian National Air Ambulance Service are specialist nurse anesthetists or intensive care nursing specialists. For air ambulance bases far from hospitals, these nurses present otherwise unavailable competencies. This study reports a 6-year experience with flight nurse participation in local emergencies beyond the transportation phase.
The fixed-wing air ambulance base in Alta, Northern Norway (20,000 inhabitants), with 2 aircraft and 2 on-call teams is 150 km by road from the nearest hospital. We did a prospective registration of all emergency nonflight missions near the air ambulance base from January 1, 2005, to December 31, 2010.
The 217 completed missions corresponded to 3 missions per month, half during daytime. Twenty-three percent of patients were under age 18, injury rate was high (36%), 63% had potentially or manifest life-threatening conditions, and 11% died during treatment. One third of all missions (67/217) resulted in an air ambulance flight to the hospital.
Mission frequency did not significantly reduce flight availability, and precision in case selection for this special service was good. The use of flight nurses in the local community promotes equal access to advanced medical services for populations far from hospitals.
Alaska Native women have encountered many obstacles in the health care system which deter them from adhering to cancer screening recommendations. To improve access, it was necessary for us to listen to them and their attitudes about health care. As a result of this assessment, we changed our approach resulting in an overall increase in screening rates from 14% to 62%. A case example is presented to demonstrate barriers to cancer screening and our techniques for overcoming them.
The Alberta Cardiac Access Collaborative (ACAC) is a joint initiative of Alberta's health system to improve access to adult cardiac services across the patient journey. ACAC has created new care delivery models and implemented best practices across Alberta in four streams across the continuum: heart attack, patient navigation, heart failure and arrhythmia. Emergency medical providers, nurses, primary care physicians, hospitals, cardiac specialists and clinicians are all working together to integrate services, bridge jurisdictions and geography with one aim--improving the patient journey for adults in need of cardiac care.