Patient care classification in Canada in the past has been largely dictated by insurance coverage and the fiscal policies of the individual provinces. In recent years, however, the Canadian Department of Health and Welfare has been promoting the development of a standard patient care classification based on assessment of client or patient needs in regard to the category, type, and level of care. Experimentation with the proposed classification system in several provinces confirms the need in long-term care to include assessment of nursing requirements, physical functioning, and psychosocial assets and liabilities, and points to the importance of using such a classification for planning and evaluating patient care as well as for administrative purposes.
The debate on health care reform in the United States has been greatly influenced by various national studies showing a strong relationship between lack of public or private health care coverage and inadequate access to health services. There is also much concern about deficiencies in the availability and delivery of services to certain population groups--especially for those living in the most remote and sparsely populated areas of the country. However, national studies have generally not demonstrated that the use of health services is strongly associated with urban/rural residence or the supply of medical providers. In this study, we show that national studies can obscure the problems of certain population groups including American Indians and Alaska Natives. Using data from the 1987 National Medical Expenditure Survey, the findings show that the availability of medical providers as well as place of residence were strongly associated with the use of health care by American Indians and Alaska Natives. Although American Indians and Alaska Natives included in this study were eligible to receive health care free of charge from the Indian Health Service (IHS), financial factors were also significantly associated with use due to the use of services other than those provided or sponsored by IHS. Also, the results show that while geographic and supply factors have only modest effects on the average travel time to medical providers for the U.S. population as a whole, travel times are dramatically longer for American Indians and Alaska Natives living in rural areas and where there are few medical providers. In addition, there appear to be fewer hospitalizations in areas where there are IHS outpatient services. We conclude by discussing the need for health care reform to take into account the diversity of a large country such as the U.S., and the special needs of population groups that are usually not adequately represented in national studies.
Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States.
All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country.
There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24).
The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.
The 65 reports of accidental lesions of the choledochus at cholecystectomy from the records of the Patients' Insurance Syndicate in Stockholm, Sweden, 1975-1982, were studied in order to characterize avoidable factors and/or situations at cholecystectomy. Compared with control materials, there were significantly less men (28 vs. 34%) and the patients were younger (46 vs. 54 years). The patients were without significant other diseases and former operations, and were slim or of a normal weight. The patients had a short history of known biliary tract disease and there was seldom a suspicion of common duct stone. Most of the surgeons were under training and 80% of them had done 25 to 100 cholecystectomies before, seldom assisted by a more experienced surgeon. The inflammation was never severe, the bleeding insignificant, and an anomaly was found after the lesion was done in only 16 of 55 cases. The lesion was done before cholangiography in 27 cases and after the cholangiography, but before the films were available in 32 cases. The gallbladder was excised about as often from the fundus as from the pouch. We have found it probable that most of these accidental injuries of the choledochus could have been prevented with a policy that considers cholecystectomy as a major operation that requires well-trained surgeons with a humble and concentrated approach to their task.
