The Canadian health care system.

Canadians have enjoyed a close and harmonious relationship with Americans for more than a century. We have learned and benefited greatly from our close association. We are pleased to share our experiences with the United States in the same spirit of mutual respect and support that has characterized our close relationship and opened our borders.     

The role of the geriatrician in managed care: opportunities and responsibilities.

Managed care offers unique opportunities to the geriatrician. Geriatricians in managed care can facilitate the provision of high quality comprehensive care for older populations and do so within reasonable financial limits. With the financial incentives of Medicare Risk contracts, the geriatrician can ensure that care is not rationed inappropriately, nor is it overutilized. As pointed out by Boult in the article on systems of care for older populations, there are several creative possibilities for programs and clinical approaches that can take advantage of the systems in place in managed care. Managed care needs to emphasize integration of multiple programs that focus on the care of the chronically ill older adult and, at the same time, prevent the fragmentation of care that so often occurs in care delivery. With so many organizations merging and the level of complexity of healthcare systems becoming increasingly complex, programs directed specifically toward the older adult must be developed and maintained. Geriatricians must be in leadership positions to ensure this happens successfully. Possible roles for the geriatrician to undertake within a managed care organization and their potential time commitment are shown in Table 1. The assumption is that in most cases each position would not be full time and that the term half-day is defined as 3 to 4 hours in a week that is made up of 10 half-days.     

Hepatitis B viral mutants and their relevance to the Canadian health care system.

Over the past 10 years, an increasing number of mutations in the hepatitis B virus genome have been described. While the majority of these mutations appear to be 'silent' or not clinically relevant, some have been described in association with increased severity of disease (core and basic core promoter mutations), evasion of immunological surveillance (S escape mutants), hepatocellular carcinogenesis (X mutants) and resistance to antiviral agents (DNA polymerase mutations). The molecular events and the clinical consequences thereof are reviewed.     

The U.S. and Canadian health care systems: views of resident physicians.

OBJECTIVE: To evaluate U.S. and Canadian resident physicians' views about their health care systems. DESIGN: Self-administered questionnaire survey in 1989. PARTICIPANTS: Senior family medicine and internal medicine residents in Canada and in ten geographically representative American states. MAIN RESULTS: American and Canadian residents had similar levels of professional satisfaction and almost universally agreed on the ethical obligation to provide care to persons of all social circumstances, but U.S. residents were more likely to perceive a serious access problem in their country (75% compared with 18%) and to think that current controls on the medical profession interfere with patient care (81% compared with 58%; P less than 0.001). In addition, U.S. residents were more likely than Canadian residents to believe that primary care salaries were too low (78% compared with 38%) and that salaries of medical subspecialists (57% compared with 17%) and surgeons (85% compared with 28%) were too high. In general, residents preferred their own country's predominant health care system. Whereas 87% of U.S. physicians supported private fee-for-service health care, 85% of Canadian physicians supported government-funded national health insurance. Nonetheless, 42% of U.S. physicians supported and only 17% strongly opposed national health insurance as an alternative approach. About two thirds of respondents from both countries opposed a salaried national health service. CONCLUSIONS: American residents perceived greater problems with access, overall intrusions into medical practice, and fee disparities than did their Canadian counterparts. They preferred private fee-for-service health care, but few strongly opposed government-funded national health insurance as an alternative approach to the health care needs of the United States.     

Interprofessional training: Geriatrics and palliative care principles for primary care teams in an ACO

ABSTRACT

There is a well-described need to increase the competence of the primary care workforce in the principles of geriatrics and palliative care, and as value-based payment models proliferate, there is increased incentive for the acquisition of these skills. Through a Geriatric Workforce Enhancement Program grant, we developed an adaptable curriculum around commonly encountered topics in palliative care and geriatrics that can be delivered to multidisciplinary clinicians in primary care settings. All participants in this training were part of an Accountable Care Organization (ACO) and were motivated to improve to care for complex older adults. A needs assessment was performed on each practice or group of learners and the curriculum was adapted accordingly. With the use of patient education and screening tools with strong validity evidence, the participants were trained in the principals of geriatrics and palliative care with a focus on advance care planning and assessing for frailty and functional decline. Comparison of pre- and post-test scores demonstrated increased confidence and knowledge in goals of care and basic geriatric assessment. Participants described feeling more able to address needs, have conversations around goals of care, and more able to recognize patients who would benefit from collaboration with geriatrics and palliative care.     

Seeking effectiveness in health care: the federal perspective

The former Health Care Financing Administration chief, now working at the White House, says that although it is important for the government to fund medical effectiveness research, input from practicing physicians is important.     

Workshops to disseminate the Canadian Thoracic Society guidelines for chronic obstructive pulmonary disease to health care professionals in Ontario: Impact on knowledge, perceived health care practices and participant satisfaction

BACKGROUND:

The Canadian Thoracic Society (CTS) has developed a clinical practice guideline (CPG) regarding the management of patients with chronic obstructive pulmonary disease (COPD). Implementation of this CPG in the primary care setting requires an effective dissemination strategy.

OBJECTIVES:

To examine the change in knowledge, participant satisfaction and perceived changes in clinical practice among health care professionals working in the primary care setting following attendance at a workshop to disseminate the CTS CPG for COPD.

METHODS:

A 2.5 h workshop was conducted in three community health sites within Ontario. Each workshop comprised a didactic presentation and interactive case study discussions. Before, and one month following the workshop, a structured knowledge assessment questionnaire was administered. A structured satisfaction questionnaire and evaluative form that examined the impact of the workshop on the clinical management of COPD patients were administered immediately and three months following completion of the workshop, respectively.

RESULTS:

Sixty-nine participants attended the workshop. The mean score for the structured knowledge assessment questionnaire increased from 8.5±2.7 to 10.6±2.0 following the workshop (P=0.008). Eighty-nine per cent and 96% of participants indicated that they would recommend the workshop to a colleague and had greater confidence in their management of COPD patients, respectively. Following attendance of the workshop, 73%, 69% and 46% described increased patient education, patient monitoring and the use of objective testing in clinical practice, respectively.

CONCLUSIONS:

Workshop attendance was associated with high levels of satisfaction and important self-reported changes in clinical practice, which may reflect improved knowledge of the CTS CPG for COPD.     

Geriatric care in the United Kingdom: an American perspective.

Geriatric care is a complex and challenging aspect of health care. The United Kingdom, with 13.6% of its population over 65 years of age, compared to 10.1% in the United States, has given special attention to this field. Characteristics of the British system include financing through the National Health Service, existence of a specialty of geriatrics, absence of "nursing homes," emphasis on home care, and avoidance of "heroics" for the terminally ill.While British life expectancy at birth is longer than that for Americans, the opposite is now true for those over 65. The British have made efforts to maximize efficiency in a high-demand, comparatively low-resource context. But there are limits to which professional dedication and patient manipulation can be pushed. Some new policy directions-primarily aimed at prevention and other methods of reducing demand, other than reimposing financial barriers-may have to be explored.