Maximum waiting time - a threat to clinical freedom? Implementation of a policy to reduce waiting times

This article focuses on physicians as implementers of health policy reforms. In 1992, a maximum waiting-time guarantee was introduced in Sweden. Initially the policy was a successful way to come to terms with long waiting times. However, after 2 years the waiting lists started to increase. To understand this development it is important to look at the reactions to the policy among the implementers, i.e. the physicians. Three questions are addressed: Did the implementers understand the intentions and the goals of the reform? Were they able to fulfil the guarantee? And, did they approve of the initiative? The study subjects were chief physicians at the hospital departments involved with the guarantee. Their attitudes towards the policy were ascertained by two surveys. Other material, such as statistics on waiting times, was also used. The study shows that the physicians approved of the guarantee initially. The measures taken in the first years were effective and did not conflict with earlier practice. However, increased demand in combination with economic restraints necessitated new priorities among patient groups. These changes of clinical practice did not coincide with the physicians' professional values and hence they became more critical to the initiative and finally chose to abandon the intentions in the guarantee.     

Aluminum in vaccines: Does it create a safety problem?

For almost a century, aluminum (Al) in the form of Al oxyhydroxide (a crystalline compound), Al hydroxyphosphate (an amorphous Al phosphate hydroxide), Al phosphate, and Al potassium sulfate has been used to improve the immunogenicity of vaccines. Al is currently included in vaccines against tetanus, hepatitis A, hepatitis B, human papillomavirus, Haemophilus influenzae type b, and infections due to Streptococcus pneumoniae and Neisseria meningitidis. Official health authorities consider the inclusion of Al in most of the presently recommended vaccines to be extremely effective and sufficiently safe. However, the inclusion of Al salts in vaccines has been debated for several years because of studies that seem to indicate that chronic Al exposure through vaccine administration can interfere with cellular and metabolic processes leading to severe neurologic diseases. Children, who in their first years of life receive several vaccine doses over a reduced period of time, would be most susceptible to any risk that might be associated with vaccines or vaccine components. The main aim of this paper was to discuss the data presently available regarding Al neurotoxicity and the risk for children receiving vaccines or other pharmaceutical preparations containing Al. Analysis of the literature showed that no apparent reason exists to support the elimination of Al from vaccines for fear of neurotoxicity. The only problem that deserves attention is the suggested relationship between Al oxyhydroxide-containing vaccines and macrophagic myofaciitis or myalgic encephalomyelitis/chronic fatigue syndrome. Currently, definitive conclusions cannot be drawn on these risks and further studies must be conducted. Until then, Al remains the best solution to improve vaccine efficacy.     

Cancer waiting times: what is the value of a lymphoma waiting time?

BACKGROUND AND AIM: Waiting times for patients with lymphoma have been reported across the United Kingdom since 2005. Lymphoma however, is not a single disease but a wide spectrum of lymphoid tumours that range from the most malignant to the most indolent, from highly curable to incurable. We now question the value of the current system that reports lymphoma waiting time on a quarterly basis and makes no allowance for the different types of lymphoma. METHOD: Four hundred and sixty nine cases of lymphoma were registered in the west of Scotland in 2004. Complete datasets were available on 428. Patient demographic data, subtypes of lymphoma, biopsy site and referral urgency data were linked to the waiting times analysis for 2004 for the three subtypes, Lymphoma (HL), Diffuse Large B Cell (DLBC) and follicular Non Hodgkin Lymp (NHL). RESULTS: Patients with HL were younger, more likely to receive urgent referral and have a diagnosis made from neck node biopsy than the other two groups. Patients with DLBC NHL however had the shortest interval between presentation and the start of treatment and were subsequently more likely to receive treatment within 62 days than patients with either follicular NHL (p < 0.001) or HL (p < 0.05). CONCLUSION: Lymphoma subtype is a major factor determining the rate of progress from presentation to the start of treatment, hence the waiting time.     

European union regulation of health technology assessment: what is required for it to succeed?

The European Journal of Health Economics -     

Emergency Department waiting times in a tertiary children’s hospital in Israel: a retrospective cohort study

Background

The purpose of this study was to assess ethnic differences in Emergency Department (ED) waiting times between Jewish and Arab children in a tertiary childrens’ hospital in Israel.

Methods

This was a retrospective cohort study of all children who were admitted to the pediatric ED of the largest hospital in northern Israel, between January 2011 and December 2015. Univariate and multivariate analyses were used to assess the strength of association between ethnicity category and waiting time. The following were tested as possible confounders: triage category, age, gender, time of arrival category. The effect of nurse-patient ethnic concordance was assessed.

Results

Full data were available in 82,883 patients, 55,497 (67.0%) Jews and 27,386 (33.0%) Arabs. Jews and Arabs had a similar median waiting time of 38 min (interquartile range [IQR] 22–63 and IQR 21–61, respectively). Ethnicity was not associated with a change in waiting time (p?=?0.36). Factors that most influenced shorter waiting time were triage category 1 (change in waiting time: ?25.5%; 95% confidence interval [CI]: ?29.3 to ?21.7), or triage category 2 (change in waiting-time: ?21.8%; 95% CI: -23.7 to ?20.05). Factors that most influenced longer waiting time were patient arrival during the morning shift period (change in waiting time: 5.45%; 95% CI: 4.59 to 6.31), or during the evening shift period (change in waiting time: 4.46%; 95% CI: 3.62 to 5.29). Ethnic discordance between triage nurses and patients did not yield longer waiting times.

Conclusion

In this large pediatric cohort, ethnic differences in ED waiting time were not found.

     

Pay in the British NHS: a local solution for a national service?

An important component of the reforms of the British National Health Service (NHS) has been devolution of a previously highly centralised pay bargaining system to the local provider level. As the wage bill is by far the single largest item of health care expenditure, the implications of this change may be far-reaching. This article surveys the available theory and evidence from an economic perspective. It reviews the development of pay determination mechanisms in the NHS and the extent to which local pay has been adopted since the reforms were introduced. It then considers the theory of local pay and general evidence on local pay variations in the UK, before turning to the available evidence on local labour markets in the health care sectors of the UK and USA. It concludes with a discussion of the policy and research implications of current developments on local pay bargaining in the NHS. In particular, it suggests that judgements over the success or failure of local pay bargaining will concern: first, whether the weakened monopsony position of the NHS at national level results in higher pay for the more powerful employee groups; second, whether fragmentation of bargaining weakens the negotiating and lobbying power of national trade unions and professional organisations; third, whether competition between providers leads to higher or lower costs; and fourth, whether any efficiency gains from local bargaining outweight the higher transaction costs involved.     

The SAFE strategy for the elimination of trachoma by 2020: will it work?

WHO has recently launched a programme (GET 2020) for the elimination of trachoma, the leading cause of preventable blindness. GET 2020 has adopted the SAFE strategy, a comprehensive set of control measures (Surgery for entropion/trichiasis; Antibiotics for infectious trachoma; Facial cleanliness to reduce transmission; Environmental improvements such as control of disease-spreading flies and access to clean water). The present article reviews the strengths and weaknesses of each component of the strategy. Although significant hurdles remain to be overcome there is every reason to hope that GET 2020 will be successful.     

Social capital: a strategy for enhancing health?

The idea of social capital is currently being discussed as a source of support for health, though it is often argued that the concept should not be used in an attempt to evolve neutral policy strategies but underlines the need for moral and political debate in health policy. This article, first, supports this argument by indicating the complex and culturally diverse nature of social capital. Its components react with their social contexts to produce a range of variants which differ from each other along several dimensions. Social solidarity and support involve different conventions in different places, with results which need appraisal before they can be supported. The article explores these issues by drawing on ethnographic material illustrating aspects of social relatedness in a variety of settings. Secondly, writers who treat social capital as invariably positive tend to associate it with conditions in the neo-liberal societies of late capitalism, even though they also see it as threatened there. Again examining social contexts, the article locates the reasons for this paradox in the cultures and structures of the societies concerned. Large-scale institutions in the West-including both those required to implement public health measures and those in which the majority of people work-are organised via neo-liberal processes which are not all conducive to the types of social relatedness which the social capital debate seeks to explore. In particular, significant aspects of social trust are difficult to support in neo-liberal organisations. The assumption that social capital can be promoted via social engineering which relies upon these very institutions is thus questionable. This, together with more positive aspects of the debate, draws attention to the need for further research on social relatedness if it is to be supported by public policy.     

Unrepresentative, invalid and misleading: are waiting times for elective admission wrongly calculated?

THESIS: The UK Government Statistical Service reports the percentage of elective 'admissions' that took place in England within 3 months of a patient being added to NHS waiting lists. This percentage is calculated from cross-sectional data using the total number of elective episodes within a specified calendar period as denominator and the number of these enrolled on the waiting list less than 3 months previously as numerator. This approach assumes that NHS waiting lists are closed and stationary populations, and has been widely used by government and non-government researchers in the UK and elsewhere. ANTITHESIS: Little attention has been given to the bias introduced when waiting lists are neither stationary nor closed. This paper identifies four groups of patients which are excluded from the denominator used by the Government Statistical Service and criticises the established method of ignoring left and right censored observations. SYNTHESIS: We describe two alternative formulae that would give the same results as the Government Statistical Service method if waiting lists were closed and stationary, but that also give unbiased results when waiting lists are open and non-stationary. They require a limited amount of additional cross-sectional data to produce upper and lower estimates of the cumulative likelihood of admission among those listed. We recommend the production of unbiased estimates by applying period life-table techniques to a complete and consistent set of 'times since enrolment'.     

Pandemic legislation in the European Union: Fit for purpose? The need for a systematic comparison of national laws

Sound governance is central to effective pandemic management. Key international legal instruments governing pandemic management in the European Union (EU): the International Health Regulations (2005) and Decision 1082/13 require EU Member States to develop national plans and invite them to establish national legal frameworks to support compliance with this international legislation. Although Member States may design the legal framework as they choose, the strongest instrument of pandemic governance is national legislation.It is currently unclear what national pandemic governance exists in Member States as it has not been mapped, i.e. identified and collated. Legal analysis and empirical evaluation of implementation and impact have therefore not been possible. We propose comprehensive mapping to create the necessary comparative data for legal analysis assessing national legislation’s compliance with international obligations and ethical principles. Empirical research could evaluate its effectiveness in promoting cross-border coherence and robust emergency response. We draw on the U.S. experience with “policy surveillance”, the systematic scientific mapping of laws of public health importance. Until national pandemic governance is mapped and evaluated, we cannot know if it is lawful, ethical or effective.     

Financial barriers to HIV treatment in Yaound��, Cameroon: first results of a national cross-sectional survey

Objective

To assess the extent to which user fees for antiretroviral therapy (ART) represent a financial barrier to access to ART among HIV-positive patients in Yaoundé, Cameroon.

Methods

Sociodemographic, economic and clinical data were collected from a random sample of 707 HIV-positive patients followed up in six public hospitals of the capital city (Yaoundé) and its surroundings through face-to-face interviews carried out by trained interviewers independently from medical staff and medical questionnaires filled out by prescribing physicians. Logistic regression models were used to identify factors associated with self-reported financial difficulties in purchasing ART during the previous 3 months.

Findings

Of the 532 patients treated with ART at the time of the survey, 20% reported financial difficulty in purchasing their antiretroviral drugs during the previous 3 months. After adjustment for socioeconomic and clinical factors, reports of financial difficulties were significantly associated with lower adherence to ART (odds ratio, OR: 0.24; 95% confidence interval, CI: 0.15–0.40; P < 0.0001) and with lower CD4+ lymphocyte (CD4) counts after 6 months of treatment (OR: 2.14; 95% CI: 1.15–3.96 for CD4 counts < 200 cells/µl; P = 0.04).

Conclusion

Removing a financial barrier to treatment with ART by eliminating user fees at the point of care delivery, as recommended by WHO, could lead to increased adherence to ART and to improved clinical results. New health financing mechanisms based on the public resources of national governments and international donors are needed to attain universal access to drugs and treatment for HIV infection.