Drug coverage in Canada: who is at risk?

Drugs are playing an increasingly important role in health care. However, unlike physician care and hospital care, Canadians do not have universal coverage for drugs. Generally, many employers provide drug coverage as part of employment benefits. In addition, provincial governments provide coverage to some parts of the population, generally, seniors and families on social assistance. Two important recent reports on the state of health care in Canada--the Kirby and Romanow reports--focus on the need for relief to families for rising cost of drugs. Policy makers need good information not only on the likely costs of such a project but also the impact of increasing drug costs on individuals and families with significant drug expenses. One of the keys to assessing scenarios for such relief is knowledge about the extent and depth of existing drug insurance coverage. However, the needed information is scattered over a number of data sources. We have put together a comprehensive and cohesive micro database synthesizing data from these diverse sources. The resultant micro database contains individual/family drug coverage information arrayed by socio-economic characteristics. This paper uses the data set to conduct an extensive analysis of the extent of drug coverage under public and private drug plans in Canada. The paper then goes on to analyze the level of such coverage in terms of out-of-pocket drug expenses faced by Canadian families in an effort to identify gaps in coverage.     

Hepatitis A: who in NSW is most at risk of infection?

The incidence of hepatitis A in NSW has declined in recent years, but the relative importance of risk factors remains unclear. METHODS: We analysed case data from the NSW Notifiable Diseases Database from 1991 to 2006. RESULTS: Hepatitis A notification rates fell from 18.9 to 1.4 cases per 100 000 between 1991 and 2006. International travel to endemic areas was the likely exposure for 50 per cent of cases between 2002 and 2006. Rates were five times higher in travellers born in countries where hepatitis A is endemic compared with those born in Australia. CONCLUSION: Travellers born in endemic countries should be carefully assessed for vaccination before departure.     

Weight-related sports involvement in girls: who is at risk for disordered eating?

A 225-item questionnaire was completed by 5163 female 7th, 9th and 11th grade public school students in their classrooms to examine factors associated with eating disorders among girls involved in weight-related sports. Eating disorder symptoms were found in almost one third of girls involved in weight-related and non-weight-related sports. However, after controlling for grade, race, SES, and study design effect, girls in weight-related sports were 51% more likely to have eating disorder symptoms. Also, among girls in weight-related sports who had eating disorders, substance abuse, physical and sexual abuse history, depressive symptoms, suicide attempts, low family communication, and low parental caring were 98% to 377% more common.     

Barriers to Medicaid enrollment: who is at risk?

OBJECTIVES: We identified factors associated with levels of knowledge about Medicaid eligibility rules and perceived Medicaid enrollment barriers. METHODS: Community health center patients who were parents of children potentially eligible for Medicaid (n=901) were interviewed in person during their clinic visit between April and December 1999. RESULTS: Individuals reporting physical health problems were more likely to be misinformed as were non-Hispanic Black individuals, compared with non-Hispanic White individuals. In states where more policies had been enacted to simplify Medicaid enrollment procedures, individuals were less likely to be misinformed. Individuals reporting mental health problems, those with less education, and women were more likely to perceive Medicaid enrollment barriers. Prior experience in Medicaid was associated with both a reduced risk of perceiving Medicaid enrollment barriers and being misinformed. CONCLUSIONS: Findings highlight target groups for whom additional outreach and additional simplification policies may be most needed.     

Point of care and patient privacy: who is in control?

Public and patient access to medical records has been severely limited through policies limiting physical and timely access and intellectual understanding of content. New expectations of patient/public access and control have arisen accompanying the new paradigms of health care delivery and health information (computer-based patient records). Examples from these new paradigms are personalized and presented in information system contexts from bedside to community settings. Patient and family involvement in care delivery, education, assessment, and control of privacy are explored. A personalized confidentiality/security/privacy module of the computer-based patient record is suggested.     

Dietary intake and eating patterns of elderly people in Israel: who is at nutritional risk?

OBJECTIVE: To determine dietary intake and eating patterns of older persons in Israel and to identify factors associated with low intake. DESIGN: A cross-sectional study. SETTING: Community-dwelling participants living in the Beer-Sheva area were interviewed at home, using a 24 h food questionnaire with additional questions regarding health and eating habits. Dietary intake was compared between people aged 65-74 and 75 y and older. SUBJECTS: A total of 377 people over the age of 65 224 aged 65-74 and 153>75, were randomly selected from the Negev population. RESULTS: Dietary intake of energy, fat, carbohydrates, vitamins E, C and B(1) were significantly lower for people aged 75 and older compared with people aged 65-74. Low energy intake was associated with lower subjective health status for men (P<0.01), poor appetite (P<0.01) and more gastrointestinal problems (P<0.05) for women and lower snack consumption (P<0.01) for both genders. In a multivariate model, low energy intake was associated with low appetite and higher use of medication for both sexes and with frequency of eating alone and not consuming snacks for men. CONCLUSIONS: Dietary intake is lower among individuals older than 75 than in 65-74 y old. Risk factors for low intake include poor appetite and health status, gastrointestinal problems, and eating alone. Snacking enhanced dietary intake and should be encouraged in this group.     

Unobserved health care expenditures: How important is censoring in register data?

Accurate information on individuals' health service use is important for evaluating health policies and analyzing health care demand. Although register data are considered to be more reliable than survey data, little is known about the extent and effect of censoring of the expenditure distribution in register data. We exploit a recent change in the health provider remuneration system in several Swiss cantons to empirically investigate whether censoring occurs when individuals do not have to disclose their health service use below their deductible level. Applying a difference‐in‐differences approach, we find that between CHF 6.70 (1.7%) to CHF 9.64 (2.4%) of all health service use paid out‐of‐pocket are not observed (per capita per year). This effect seems to be driven by high‐deductible plans where observed out‐of‐pocket expenditures declined by CHF 30.34 (7.6%) after the change. Although statistically significant, these effects are almost negligible in economic terms. We therefore concluded that, if anything, censoring is a very limited issue in Swiss health insurance claims data.     

Who is at risk of death in an earthquake?

Although, theoretically, the impacts of a disaster are not randomly distributed across health and socioeconomic classes, empirical evidence of this claim is scarce. In a population-based cohort study, the authors identified risk factors for mortality from the September 21, 1999, Taiwan earthquake, which occurred in the middle of the night. Among 297,047 earthquake victims in central Taiwan who experienced partial or complete dwelling damage, 295,437 (noncases) survived the earthquake and 1,610 (cases) died between September 21 and October 31, 1999. Odds ratios were adjusted for both micro-level individual variables and macro-level neighborhood variables. People with mental disorders (odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.1, 3.5), people with moderate physical disabilities (OR = 1.7, 95% CI: 1.2, 2.3), and people who had been hospitalized just prior to the earthquake (OR = 1.4, 95% CI: 1.2, 1.7) were the most vulnerable. The degree of vulnerability increased with decreasing monthly wage (measured in New Taiwanese dollars (NT$)) (NT$20,000 approximately NT$39,999: OR = 1.5, 95% CI: 1.1, 2.1; 相似文献   

Heat‐related and cold‐related deaths in England and Wales: who is at risk?

Background

Despite the high burden from exposure to both hot and cold weather each year in England and Wales, there has been relatively little investigation on who is most at risk, resulting in uncertainties in informing government interventions.

Objective

To determine the subgroups of the population that are most vulnerable to heat‐related and cold‐related mortality.

Methods

Ecological time‐series study of daily mortality in all regions of England and Wales between 1993 and 2003, with postcode linkage of individual deaths to a UK database of all care and nursing homes, and 2001 UK census small‐area indicators.

Results

A risk of mortality was observed for both heat and cold exposure in all regions, with the strongest heat effects in London and strongest cold effects in the Eastern region. For all regions, a mean relative risk of 1.03 (95% confidence interval (CI) 1.02 to 1.03) was estimated per degree increase above the heat threshold, defined as the 95th centile of the temperature distribution in each region, and 1.06 (95% CI 1.05 to 1.06) per degree decrease below the cold threshold (set at the 5th centile). Elderly people, particularly those in nursing and care homes, were most vulnerable. The greatest risk of heat mortality was observed for respiratory and external causes, and in women, which remained after control for age. Vulnerability to either heat or cold was not modified by deprivation, except in rural populations where cold effects were slightly stronger in more deprived areas.

Conclusions

Interventions to reduce vulnerability to both hot and cold weather should target all elderly people. Specific interventions should also be developed for people in nursing and care homes as heat illness is easily preventable.The large death toll and disruption associated with the bitterly cold weather in Central and Eastern Europe in the winter of 2005–6 was a timely reminder of how poorly prepared many populations are to the dangers of extreme cold temperatures (http://news.bbc.co.uk/1/hi/world/europe/4643718.stm). Similarly, the dangers of hot weather were shown dramatically by the 2003 heat wave that accounted for >30 000 deaths throughout western Europe,¹ and >2000 deaths in England and Wales alone.²Health protection measures are being increasingly developed. The Department of Health''s heatwave plan for England was implemented rapidly in 2004 and includes monitoring of health surveillance data.³ Measures to prevent cold‐related mortality currently focus on activities to reduce fuel poverty and improve home insulation,⁴ as well as advise about behaviour when outdoors.⁵ However, many uncertainties remain in the identification of those most vulnerable to both hot and cold weather and the most effective means of health protection.Excess winter mortality in the UK, although falling, is higher than in other European countries.⁶ Some of this high winter burden can be explained by behavioural factors reflecting poor adaptation to cold weather,^7,8 and poorly insulated housing also has a key role.⁴ It has been observed that winter mortality can be higher among lower social classes^9,10; however many others have observed no association with deprivation in the UK,^{11,12,13,14,15,16,17} which is consistent with poorly heated homes being more prevalent in the middle classes.Information from heatwave events in the US and Europe suggests that vulnerability to heat can be modified by intrinsic factors such as age,² sex^18,19 and possibly race.²⁰ Other “acquired” characteristics may also predispose individuals to heightened susceptibility to environmental exposures.²¹ These include pre‐existing medical conditions such as cardiorespiratory diseases, neurological diseases and mental illness.¹⁹As with cold, the evidence for whether effects of heat are modified by socioeconomic status is unclear. Studies from the US have observed an association with deprivation,^{22,23,24,25,26} where lack of air conditioning is a strong marker for poverty. However, other work, using area‐level indicators, observed no modification of the heat effect in Sao Paulo.²⁷ Other contextual characteristics that increase susceptibility to heat exposure are social isolation,^28,29 living in urban areas³⁰ and living on the top floors of buildings.³¹ Many deaths in France during the 2003 heat wave occurred in nursing and residential homes.³² Important differences in heatwave mortality were also reported between cities in Europe.¹ The population in the northern part of France, away from the Atlantic coast, was most affected.³³By using long time‐series datasets of daily mortality counts for each region of England and Wales, we investigated which subgroups of people are most at risk from exposure to hot and to cold weather. Risk factors were identified by linkage of mortality files to small area‐level variables on the 2001 UK census and to a database of all care and nursing homes to determine whether or not individuals were residents of care homes at the time of death.     

Team care: solution for hospital oncology units?

Team care promises improved patient care through improved coordination of existing hospital services, as well as continuity of care for the patient between the hospital and the home. Commitment to the team concept, however, calls for more than lip service.     

Does substituting home care for institutional care lead to a reduction in Medicaid expenditures?

In 1981 Congress introduced Home and Community Based Services (HCBS) waivers in an attempt to contain Medicaid long-term care expenditures. This paper analyzes the efficacy of the waiver program. To date, little is known about its impact on cost containment. Using state-level Medicaid data on expenditures and the number of individuals participating in HCBS waivers between 1992 and 2000, this study estimates the impact of HCBS waivers on total Medicaid expenditures as well as on Medicaid institutional, home health and pharmaceutical expenditures. A fixed effects model is used to analyze Medicaid expenditures using variation in the size of HCBS waiver programs across states and over time. The results, robust across multiple specifications, show increases rather than decreases in total Medicaid spending as well as increases in the other Medicaid spending categories analyzed. This implies that there is no evidence of substitution from institutional care to the HCBS waiver program or that cost-shifting is occurring. In fact, the large magnitude of the estimated spending increases suggests the waivers may induce more people to enter the Medicaid program.     

Intention-to-treat analysis: who is in? Who is out?

To assess whether the term "intention to treat" (ITT) predicts inclusion of all randomized subjects in the analysis, we reviewed 100 randomly selected reports of randomized trials that mentioned analysis by ITT. Only 42 of 100 reports included all randomized subjects in the ITT analysis. We could not determine which categories of participants were excluded from the ITT analysis in 13 trials. The most common categories of excluded subjects were patients who, after randomization, received no follow-up (16/100), received no treatment (14/100), or were found not to meet study entry criteria (12/100). We could determine the number of participants in the ITT analysis for 92 studies. Nineteen of the 92 studies excluded more than 5% of randomized participants, and 10 excluded more than 10%. There is considerable variation in how researchers define and apply the principle of intention to treat.     

Inadequacies of death certification in Beirut: who is responsible?

OBJECTIVE: To assess the completeness of data on death certificates over the past 25 years in Beirut, Lebanon, and to examine factors associated with the absence of certifiers' signatures and the non-reporting of the underlying cause of death. METHODS: A systematic 20% sample comprising 2607 death certificates covering the 1974, 1984, 1994, 1997 and 1998 registration periods was retrospectively reviewed for certification practices and missing data. FINDINGS: The information on the death certificates was almost complete in respect of all demographic characteristics of the deceased persons except for occupation and month of birth. Data relating to these variables were missing on approximately 95% and 78% of the certificates, respectively. Around half of the certificates did not carry a certifier's signature. Of those bearing such a signature, 21.6% lacked documentation of the underlying cause of death. The certifier's signature was more likely to be absent on: certificates corresponding to the younger and older age groups than on those of persons aged 15-44 years; those of females than on those of males; those of persons who had been living remotely from the registration governorate than on those of other deceased persons; and those for which there had been delays in registration exceeding six months than on certificates for which registration had been quicker. For certificates that carried the certifier's signature there was no evidence that any of the demographic characteristics of the deceased person was associated with decreased likelihood of reporting an underlying cause of death. CONCLUSION: The responsibility for failure to report causes of death in Beirut lies with families who lack an incentive to call for a physician and with certifying physicians who do not carry out this duty. The deficiencies in death certification are rectifiable. However, any changes should be sensitive to the constraints of the organizational and legal infrastructure governing death registration practices and the medical educational systems in the country.     

Patient assessments of hospital maternity care: a useful tool for consumers?

OBJECTIVE: To examine three issues related to using patient assessments of care as a means to select hospitals and foster consumer choice-specifically, whether patient assessments (1) vary across hospitals, (2) are reproducible over time, and (3) are biased by case-mix differences. DATA SOURCES/STUDY SETTING: Surveys that were mailed to 27,674 randomly selected patients admitted to 18 hospitals in a large metropolitan region (Northeast Ohio) for labor and delivery in 1992-1994. We received completed surveys from 16,051 patients (58 percent response rate). STUDY DESIGN: Design was a repeated cross-sectional study. DATA COLLECTION: Surveys were mailed approximately 8 to 12 weeks after discharge. We used three previously validated scales evaluating patients' global assessments of care (three items)as well as assessments of physician (six items) and nursing (five items) care. Each scale had a possible range of 0 (poor care) to 100 (excellent care). PRINCIPAL FINDINGS: Patient assessments varied (p<.001) across hospitals for each scale. Mean hospital scores were higher or lower (p<.01) than the sample mean for seven or more hospitals during each year of data collection. However, within individual hospitals, mean scores were reproducible over the three years. In addition, relative hospital rankings were stable; Spearman correlation coefficients ranged from 0.85 to 0.96 when rankings during individual years were compared. Patient characteristics (age, race, education, insurance status, health status, type of delivery) explained only 2-3 percent of the variance in patient assessments, and adjusting scores for these factors had little effect on hospitals' scores. CONCLUSIONS: The findings indicate that patient assessments of care may be a sensitive measure for discriminating among hospitals. In addition, hospital scores are reproducible and not substantially affected by case-mix differences. If our findings regarding patient assessments are generalizable to other patient populations and delivery settings, these measures may be a useful tool for consumers in selecting hospitals or other healthcare providers.