Rationing health care to disabled people

Combining a political economic perspective with a case study approach, this paper examines the intent, process, and consequences of rationed care for disabled people under the U.S. managed care system. Two disabled persons were followed over a three‐year period as they sought care for major episodes relating to chronic depression and post‐polio syndrome. The findings illustrate a marked disparity between the concept and goals of rationed care and the experience of consumers of services. For these people, care is rationed at the service level and also in terms of restricted access to, and payment for, the care sought. This often results in inadequate treatment and inflated costs. These problems are due in large part to the competitive nature of the major stakeholders, institutional coalitions that work against patients, emphasis on profit maximisation, devaluing of the lives of disabled people and the weak bargaining position that disabled persons hold as consumers.     

Microfinance as a tool for financing medical devices in Syria. An assessment of needs and a call for further research

Background

Microfinance is a generally accepted tool for improving the economic situation of the poor in developing countries. However, it has hardly been used to finance medical devices required by the disabled, although the incapability of these groups to buy wheelchairs and other equipment is a major source of poverty.

Aim

This paper analyzes the need for microfinance as a tool for financing wheelchairs for patients suffering from a walking disability and oxygen concentrators for patients with chronic lung diseases. It is not in the scope of this study to present a comprehensive concept of implementing a microfinance instrument, but the paper intends to demonstrate that the disabled in Syria perceive a great need for such a financing tool. In addition, this paper wants to encourage microfinance institutions to go beyond their traditional field of business and start lending to the disabled so that they can buy the equipment necessary to live a productive life of higher quality.

Methodology

Two groups of disabled patients in Syria were asked about their social and economic situation as well as their access to financing tools. The first sample consisted of patients suffering from a walking disability with major constraints concerning their mobility and who are in need of a wheelchair (N?=?100). The second sample consisted of patients with chronic lung diseases (N?=?90) and with a need of additional oxygen. All participants lived below the national poverty line.

Results

Eighty-two percent of the interviewees suffering from a walking disability and 78% of the interviewees with chronic lung diseases were not health-insured. Although there was some knowledge of microfinance among the interviewees, they reported having limited or no access to such programs. Seventy-two percent of the patients with a walking disability and 68% of the patients with chronic lung diseases knew what microfinance is, but the portion of borrowers was 24% of the examined patients with a walking disability and 22% of the patients with chronic lung diseases. Ninety percent of the patients with a walking disability and 73% of the patients with a chronic lung disease are convinced that they could generate income if they could only buy a wheelchair or an oxygen concentrator. The majority, i.e., 89% of the patients with a walking disability and 95% of the patients with a chronic lung disease, believed that microfinance would be an ideal tool for them to finance these devices and that they or their family could pay back the installments.

Conclusion

Microfinance has not been used as a tool for financing medical devices in Syria. However, this study shows that the disabled of this country perceive a great need for this innovative system. The majority of the disabled believe that they could gain some income and pay back the loan if they had the necessary equipment. This is a basic prerequisite for further steps to start microfinance for this group of potential clients. However, a start-up would need some support, e.g., by the government of Syria. It is likely that the financing of medical devices by microfinance can also be used for other groups of patients and needy persons in Syria as well as in comparable countries, but this statement calls for further research.     

Organization of the activities of an outpatient department of a regional pulmonologic center

Ten years of experience in the work of specialized pulmonary centre providing care for the population of the region has indicated that during this period it has had a major impact on health care delivery and quality of care for the pulmonary patients. There has been improvement in early diagnosis and outcomes of treatment in patients with pulmonary diseases. The primary invalidism associated with chronic non-specific lung diseases has tended to decrease.     

Opportunities for health promotion: including the chronically ill and disabled

One of the aims of health promotion and illness prevention is to reduce the prevalence of chronic disease that is so apparent in the developed countries, yet the very individuals who already have chronic diseases and disabling conditions constitute a sizeable population which could contribute to health promotion programs. There are two chief elements which argue for an extension of health promotion toward the chronically ill and disabled: (1) the lifestyle management which is characteristic of health promotion is similar in many respects to the comprehensive self-care regimens followed by chronically ill persons, and (2) the philosophy of independent living for disabled persons shares social foundations with the concept of health promotion and could add the strength of social advocacy to health promotion. This paper examines social and medical variables linking the two health trends of health promotion and independent living for disabled persons. Observations of a U.S. independent living program, The Timbers, are reported to illustrate an active combination of the two philosophies. Finally, sociological implications are presented, with a focus on the potential of health promotion programs.     

Do disease specific characteristics add to the explanation of mobility limitations in patients with different chronic diseases? A study in The Netherlands.

STUDY OBJECTIVES: To determine whether disease specific characteristics, reflecting clinical disease severity, add to the explanation of mobility limitations in patients with specific chronic diseases. DESIGN AND SETTING: Cross sectional study of survey data from community dwelling elderly people, aged 55-85 years, in the Netherlands. PARTICIPANTS AND METHODS: The additional explanation of mobility limitations by disease specific characteristics was examined by logistic regression analyses on data from 2830 community dwelling elderly people. MAIN RESULTS: In the total sample, chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, diabetes mellitus, stroke, arthritis and cancer (the index diseases), were all independently associated with mobility limitations. Adjusted for age, sex, comorbidity, and medical treatment disease specific characteristics that explain the association between disease and mobility mostly reflect decreased endurance capacity (shortness of breath and disturbed night rest in chronic non-specific lung disease, angina pectoris and congestive heart failure in cardiac disease), or are directly related to mobility function (stiffness and lower body complaints in arthritis). For atherosclerosis and diabetes mellitus, disease specific characteristics did not add to the explanation of mobility limitations. CONCLUSIONS: The results provide evidence that, to obtain more detailed information about the differential impact of chronic diseases on mobility, disease specific characteristics are important to take into account.     

基质金属蛋白酶9及其组织抑制因子1在社区获得性 肺炎和肺结核鉴别诊断中的价值*

摘 要：保持孕妇体内微生态系统的动态平衡对保护母婴健康至关重要。胎盘是胎儿与母体之间进行物质交换的重要器 官，长期以来均被认为是无菌的。然而，最新的多重组织学和高通量测序研究结果显示，即使在没有感染的情况下，胎盘和 胎膜可能也不是无菌的，相反胎盘有着不同于其他器官系统的、丰富的微生物群。据有关报道显示，胎盘上的微生物会直接 影响胎儿的健康, 可能会导致胎儿早产甚至流产。世界卫生组织估计，每年约有1 500万名婴儿早产，早产是导致婴幼儿患病 和死亡的主要原因，严重威胁孕妇和胎儿健康。文章就胎盘微生态与早产的研究进展进行综述，旨在为临床早期胎盘微生态 的监测和早产的预防提供参考依据。     

Comparison between cohorts vaccinated and unvaccinated against influenza and pneumococcal infection

This study characterizes possible confounders that might make cohorts vaccinated and unvaccinated against influenza and pneumococcal infection different at baseline, with the hypothesis that the two cohorts are comparable. The similarity between health and demographic data was analysed by a randomized, multivariant study addressed to 10,000 persons aged 65 years and older in Stockholm County and was carried out in the form of a postal inquiry during the period December 2000 to May 2001. The study-population response rate was 78%. Of these, 66% (5,120 persons) had been given at least one influenza vaccination during the 3-year study period (1998-2000), 50% (3,780) had received one pneumococcal vaccination and 78% had received both vaccines during the period. The vaccination rate was lower in the age group 65-69 years (60%), compared with elderly cohorts aged over 70 years (67-72%, P < 0.001). Elderly persons living in nursing homes or institutions had higher vaccination rates than persons living in their own households (72 vs. 67%). Persons with underlying chronic diseases had higher vaccination rates (71%, P < 0.001) than those without underlying chronic diseases. Vaccine recipients had fewer days in hospital, compared with non-recipients. Unvaccinated persons with myocardial disease had nine times more days in hospital than vaccinated persons with myocardial disease. Vaccination against pneumococcal infection had an additional effect with influenza vaccination in reducing hospitalization for chronic lung diseases; influenza vaccination alone did not have this effect. In conclusion, the influenza and pneumococcal-vaccine recipients were older and had significantly more chronic lung and heart conditions than the unvaccinated cohort.     

Open lung biopsy in severely ill patients with unrecognized pulmonary infiltrates

In three patients, a man aged 34 with aids, a woman aged 67 with recurrent major dyspnoea and a woman aged 73 with chronic lymphatic leukaemia, examination revealed progressive dyspnoea while the chest X-rays showed infiltrative lesions in both lungs. In view of the inadequate response to the treatment administered, an open lung biopsy was performed, following which the diagnosis could be made. Adequate treatment was then started and followed by clinical recovery. It is not clear if open lung biopsy carries higher risks of mortality and morbidity than biopsy by means of flexible bronchoscopy. Open lung biopsy more often leads to a classifying diagnosis. For collection of endobronchial or transbronchial biopsy samples in ununderstood diffuse interstitial lung diseases, flexible bronchoscopy is the method of first choice. Open lung biopsy is a justified supplementary examination, at any rate in severely ill, immunocompromised patients who require adequate therapy without delay.     

The effect of dietary components on inflammatory lung diseases – a literature review

Anti-inflammatory treatment in chronic inflammatory lung diseases usually involves glucocorticosteroids. With patients suffering from serious side effects or becoming resistant, specific nutrients, that are suggested to positively influence disease progression, can be considered as new treatment options. The dietary inflammatory index is used to calculate effects of dietary components on inflammation and lung function to identify most potent dietary components, based on 162 articles. The positive effects of n-3 PUFAs and vitamin E on lung function can at least partially be explained by their anti-inflammatory effect. Many other dietary components showed only small or no effects on inflammation and/or lung function, although the number of weighted studies was often too small for a reliable assessment. Optimal beneficial dietary elements might reduce the required amounts of anti-inflammatory treatments, thereby decreasing both side effects and development of resistance as to improve quality of life of patients suffering from chronic inflammatory lung diseases.     

Mortality in a large population-based cohort of patients with drug-treated diabetes mellitus.

OBJECTIVES: This paper presents detailed cause-specific data about excess mortality among diabetic persons in Finland, by age and sex. METHODS: Five-year follow-up data on the Finnish population aged 30 through 74 years were analyzed. During these 5 years, 11,215 persons with diabetes and 102,843 persons without diabetes died. The diabetic population was defined as people who were entitled to free medication for diabetes at the beginning of the follow-up period, that is, at the end of 1980. RESULTS: The relative mortality of persons with drug-treated diabetes compared with nondiabetic persons was higher among women (3.4) than among men (2.4). Almost three quarters of the mortality excess was due to circulatory diseases. For most other causes of death, too, diabetic persons had higher than average mortality. The exceptions were lung cancer, chronic obstructive pulmonary disease, and alcohol poisoning. CONCLUSIONS: Diabetes is a general risk factor for untimely death and makes a significant contribution to overall national death rates, particularly for circulatory diseases. Lower than average mortality from smoking-related diseases and alcohol poisoning, however, warrant optimism about the effects of health education among diabetic persons.     

Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study.

OBJECTIVES: This study detected secular change in disability and health among persons aged 55 to 70 years, the life period when increases in disability and morbidity begin and retirement occurs. METHODS: Cross-sectional comparisons were completed with data from similarly aged members of the original (n = 1760) and offspring (n = 1688) cohorts of the Framingham Heart Study, which represent 2 generations. Analyses were conducted by gender and on chronic disease subgroups by logistic regression. RESULTS: There was substantially less disability in the offspring cohort than in the original cohort. Thirty-six percent of offspring men were disabled vs 52% of original cohort men (P = .001); among women, these proportions were 54% vs 72% (P = .001). Fewer offspring perceived their health as fair or poor and fewer had chronic diseases. Offspring were more physically active and less likely to smoke or consume high amounts of alcohol, but their average weight was greater. The secular decline in disability was strongly evident among individuals with chronic diseases. CONCLUSIONS: Our findings depict a secular change toward a less disabled and globally healthier population in the period of life when retirement occurs.     

Seasonal influenza vaccine coverage among high-risk populations in Thailand, 2010–2012

BackgroundThe Advisory Committee on Immunization Practice of Thailand prioritizes seasonal influenza vaccinations for populations who are at highest risk for serious complications (pregnant women, children 6 months–2 years, persons ≥65 years, persons with chronic diseases, obese persons), and healthcare personnel and poultry cullers. The Thailand government purchases seasonal influenza vaccine for these groups. We assessed vaccination coverage among high-risk groups in Thailand from 2010 to 2012.MethodsNational records on persons who received publicly purchased vaccines from 2010 to 2012 were analyzed by high-risk category. Denominator data from multiple sources were compared to calculate coverage. Vaccine coverage was defined as the proportion of individuals in each category who received the vaccine. Vaccine wastage was defined as the proportion of publicly purchased vaccines that were not used.ResultsFrom 2010 to 2012, 8.18 million influenza vaccines were publicly purchased (range, 2.37–3.29 million doses/year), and vaccine purchases increased 39% over these years. Vaccine wastage was 9.5%. Approximately 5.7 million (77%) vaccine doses were administered to persons ≥65 years and persons with chronic diseases, 1.4 million (19%) to healthcare personnel/poultry cullers, 82,570 (1.1%) to children 6 months–2 years, 78,885 (1.1%) to obese persons, 26,481 (0.4%) to mentally disabled persons, and 17,787 (0.2%) to pregnant women. Between 2010 and 2012, coverage increased among persons with chronic diseases (8.6% versus 14%; p < 0.01) and persons ≥65 years (12%, versus 20%; p < 0.01); however, coverage decreased for mentally disabled persons (6.1% versus 4.9%; p < 0.01), children 6 months–2 years (2.3% versus 0.9%; p < 0.01), pregnant women (1.1% versus 0.9%; p < 0.01), and obese persons (0.2% versus 0.1%; p < 0.01).ConclusionsFrom 2010 to 2012, the availability of publicly purchased vaccines increased. While coverage remained low for all target groups, coverage was highest among persons ≥65 years and persons with chronic diseases. Annual coverage assessments are necessary to promote higher coverage among high-risk groups in Thailand.     

成都市老年人慢性疾病患病调查

目的 了解成都市老年人的健康情况,以及各类慢性疾病的患病率及分布特征,为制订成都市老年人医疗保健服务对策提供依据。方法 研究人群来自成都市一个社区的全体老年人和四川省老年大学的学员,年龄在60岁以上的老人330人进行调查。结果 调查人群的慢性疾病排列次序由高及低依次为：肌肉骨骼系统疾病（72．4％）、消化系统疾病（47．0％）、心血血管疾病（43．8％）、呼吸系统疾病（31．3％）、皮肤病（28．3％）、泌尿系统疾病（18．4％）。不同经济收入水平人群组各种慢性病患病率有所不同。结论 要改善和提高老年人的医疗服务水平,医疗卫生部门应该充分考虑到老年人疾病谱的特点,开展有针对性的医疗服务项目。     

Attitude of medical students toward the handicapped

In their daily professional work physicians are increasingly faced with persons who live with chronic diseases or handicaps. Beyond profound medical knowledge, an understanding of psychosocial factors and a positive attitude are essential for providing optimal treatment. In order to teach the medical students of Leipzig University how to balance these factors they are required to visit self-help groups and institutions for disabled persons as part of the course "Social Medicine". 250 medical students of the 9th semester filled out a questionnaire designed to assess their attitudes toward handicapped persons as well as their motivation for choosing the medical profession. The questionnaire was given twice, once before their visitations and once following. 28 students of special supportive education served as a control group. While the attitudes of the medical students were very similar to those of the standard population, the attitudes of the supportive education students were significantly more positive. A comparison of the results of the questionnaires before and after the visitations showed that the attitudes of the medical students remained essentially the same without any obvious changes due to their experiences during the visitations. This evidence suggests that there needs to be more emphasis in Social Medicine and medical education in general placed on the problems specific to handicapped people.     

Immunity and non-specific defense in workers exposed to chronic action of low-dosage ionizing radiation (review of the literature)

The article contains a review of some medical literature data on the current state of non-specific protection and immunity in persons exposed to chronic actions of low-dosage ionizing radiation. Both in the 60s, when the occupation-related levels of ionizing radiation not infrequently exceeded MALs, and in the 80s, when such levels were considerably lowered, most researchers stressed the possibility of inhibiting the non-specific protection, T- and B-systems indices, formation of allergies and autoallergies. The changes and developments are considered by the authors a result of a complex action of both radiation and non-radiation-induced industrial factors.     

Quality of life from the perspective of persons with chronic respiratory diseases: the contribution of a social group

This convergent care research was carried out in a social group of persons with chronic respiratory diseases and aimed to identify the elements affecting the quality of life of persons with chronic respiratory problems, and to understand how the educative practice in a social group has contributed to the quality of life of persons with a chronic health condition. Data were collected at group meetings, during which the statements of eleven subjects and two family members were tape-recorded. Data analysis showed that controlling conflicting feelings, continuing to fight for a better life, overcoming one's limitations brought about by disease and treatment and getting family support are factors that affect the quality of life of persons with chronic respiratory problems. The study also made evident that health education acquired through social groups brings effective outcomes in promoting quality of life among the study participants.     

Ethical aspects of sexuality of persons with mental retardation

Current trends towards normalization of the disabled provide opportunities especially for mentally retarded adolescents to enjoy satisfying sexual experiences. However, the right of mentally disabled persons to their own sexuality has become an emotionally discussed topic among professionals and lay people because of concerns about unwanted pregnancies, venereal diseases and sexual exploitation. The key ethical issue is the acceptance of the human rights of personal inviolability, self determination in marrying and founding a family and voluntary procreation of mentally disabled persons in respect to prevailing parent-family and parent-citizen models. It is argued that in discussing ethical aspects of the sexuality of mentally disabled persons standards of consistency should be upheld by applying principles fundamental to modern ethics.     

Age and capacity devaluation: a replication

This study replicates and extends an earlier study of disabled men based on 1966 national survey data which supported the hypothesis of capacity devaluation among older persons who considered themselves disabled, by finding that age was related to self-reported severity of work disability independent of several measures of functional capacity loss and prior job requirements. We analyzed data from a 1972 national survey of disabled persons in the U.S. aged 20-64 for women as well as men, utilizing more comprehensive and direct measures of capacity loss and prior work situation. Cross-tabular and logit analyses largely confirm the finding in the earlier study and extend them to disabled women: age independently affected self-perceived severity of work disability. Capacity devaluation among the near-aged occurred particularly among less incapacitated blue-collar men but its occurrence was not greater among those with more specific exertional requirements in the prior job. The results generally support the conclusion that older persons with work limitations devalue their residual capacities for work. Older persons' evaluations of their work abilities appear to be influenced by social expectations of declining capacities with age and by social sanctions permitting premature withdrawal from work for reasons of health.     

Potency: a readjustment-promoting link in the rehabilitation of disabled persons

Abstract A study among a stratified sample of Israeli disabled war veterans ascertained the contribution of 'potency' - a recently discerned stress-moderating link in the coping process - in promoting the readaptation to social life of traumatically disabled persons. Potency reflects a combination of self-confidence and commitment to and trust in society. The data suggest that potency is likely to weaken the deleterious impact of inadequate coping with the unprecedented demands inherent in disability. Disabled army veterans with strong potency are less likely than those with weak potency to be affected by occasional coping failures, by subjectively perceived 'demands', or by occasional resource deficiencies. The evident instrumentality of potency for readjustment suggests that societal and personal factors simultaneously play a significant role in readjustment.
The contribution of this study is in its illumination of the importance of the disabled person's perception of society, in addition to his/her individual resources, for successful reintegration into social life.     

Disabled persons in Poland

It is generally considered that disability is an important social problem. This was expressed for example by the decision of the United Nations Organisation to nominate 1981 as the International Year of the Disabled. The number of disabled is one of the main problems. For social planning, the proper allocation of goods and resources for changes in the attitudes of society towards disability it is necessary to identify the prevalence, distribution and composition of the disabled. Prior to the 1978 Census, in Poland there was no information available on disability except the number of disabled persons legally classified by the Medical Board for Disability and Employment receiving disability pension, as well as the average amount of such pension, the number of disability certificates issued annually, the number of employed and the number employed in co-operatives for the disabled. The social criterion--major social role associated with psycho-physical state--was the main concept of the investigation on the frequency of disability in 1978 Census. Methodology used in this study of disability was based on the U.S. experience gained from the 1970 NC, as well as on the NCHS Survey of psychophysical causes of permanent limitation of social role performance and locomotion, performed since 1957. It should be explained, however, that the scope of disability investigated in NCHS Survey and in Polish Census is exactly the same and much wider than in U.S. Censuses. The Polish National Census revealed that there are 2,485,001 disabled persons in Poland, i.e. 7.1% of the total population. The urban population constituted 57.7% and the inhabitants of rural areas 42.5% of the total population.(ABSTRACT TRUNCATED AT 250 WORDS)