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Andersen SK, Gamble N, Rewa O. COVID-19 critical care triage across Canada: a narrative synthesis and ethical analysis of early provincial triage protocols. Can J Anaesth 2024:10.1007/s12630-024-02744-y. [PMID: 38589739 DOI: 10.1007/s12630-024-02744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 12/23/2023] [Accepted: 01/10/2024] [Indexed: 04/10/2024] Open
Abstract
PURPOSE The COVID-19 pandemic created conditions of scarcity that led many provinces within Canada to develop triage protocols for critical care resources. In this study, we sought to undertake a narrative synthesis and ethical analysis of early provincial pandemic triage protocols. METHODS We collected provincial triage protocols through personal correspondence with academic and political stakeholders between June and August 2020. Protocol data were extracted independently by two researchers and compared for accuracy and agreement. We separated data into three categories for comparative content analysis: protocol development, ethical framework, and protocol content. Our ethical analysis was informed by a procedural justice framework. RESULTS We obtained a total of eight provincial triage protocols. Protocols were similar in content, although age, physiologic scores, and functional status were variably incorporated. Most protocols were developed through a multidisciplinary, expert-driven, consensus process, and many were informed by influenza pandemic guidelines previously developed in Ontario. All protocols employed tiered morality-focused exclusion criteria to determine scarce resource allocation at the level of regional health care systems. None included a public engagement phase, although targeted consultation with public advocacy groups and relevant stakeholders was undertaken in select provinces. Most protocols were not publicly available in 2020. CONCLUSIONS Early provincial COVID-19 triage protocols were developed by dedicated expert committees under challenging circumstances. Nonetheless, few were publicly available, and public consultation was limited. No protocols were ever implemented, including during periods of extreme critical care surge. A national approach to pandemic triage that incorporates additional aspects of procedural justice should be considered in preparation for future pandemics.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, AB, T6G 2G3, Canada.
- Alberta Health Services, Edmonton, AB, Canada.
| | - Nathan Gamble
- Alberta Health Services, Edmonton, AB, Canada
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Oleksa Rewa
- Alberta Health Services, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Blaszczak W, White B, Monterisi S, Swietach P. Dynamic IL-6R/STAT3 signaling leads to heterogeneity of metabolic phenotype in pancreatic ductal adenocarcinoma cells. Cell Rep 2024; 43:113612. [PMID: 38141171 DOI: 10.1016/j.celrep.2023.113612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/29/2023] [Accepted: 12/07/2023] [Indexed: 12/25/2023] Open
Abstract
Malignancy is enabled by pro-growth mutations and adequate energy provision. However, global metabolic activation would be self-terminating if it depleted tumor resources. Cancer cells could avoid this by rationing resources, e.g., dynamically switching between "baseline" and "activated" metabolic states. Using single-cell metabolic phenotyping of pancreatic ductal adenocarcinoma cells, we identify MIA-PaCa-2 as having broad heterogeneity of fermentative metabolism. Sorting by a readout of lactic acid permeability separates cells by fermentative and respiratory rates. Contrasting phenotypes persist for 4 days and are unrelated to cell cycling or glycolytic/respiratory gene expression; however, transcriptomics links metabolically active cells with interleukin-6 receptor (IL-6R)-STAT3 signaling. We verify this by IL-6R/STAT3 knockdowns and sorting by IL-6R status. IL-6R/STAT3 activates fermentation and transcription of its inhibitor, SOCS3, resulting in delayed negative feedback that underpins transitions between metabolic states. Among cells manifesting wide metabolic heterogeneity, dynamic IL-6R/STAT3 signaling may allow cell cohorts to take turns in progressing energy-intense processes without depleting shared resources.
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Affiliation(s)
- Wiktoria Blaszczak
- Department of Physiology, Anatomy & Genetics, University of Oxford, Sherrington Building, Parks Road, OX1 3PT Oxford, UK
| | - Bobby White
- Department of Physiology, Anatomy & Genetics, University of Oxford, Sherrington Building, Parks Road, OX1 3PT Oxford, UK
| | - Stefania Monterisi
- Department of Physiology, Anatomy & Genetics, University of Oxford, Sherrington Building, Parks Road, OX1 3PT Oxford, UK
| | - Pawel Swietach
- Department of Physiology, Anatomy & Genetics, University of Oxford, Sherrington Building, Parks Road, OX1 3PT Oxford, UK.
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Awua AK. Ration health resources to save more statistical lives from cervical cancer death in Africa: Why are we allowing them to die? Dev World Bioeth 2023. [PMID: 37966998 DOI: 10.1111/dewb.12434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023]
Abstract
Public health interventions, particularly in low- and middle-income countries (LMICs), are implemented with the never-ending challenge of limited resources and the ever-present challenge of choosing between interventions. While necessary, the application of ethical analysis is absent in most of such decision-making, resulting in fewer favourable consequences. In applying ethical principles to the saving of women from the burden of cervical cancer, I argue in favour of saving statistical lives (investing in prevention) in LMICs, by mapping the principles of justice in resource allocation to the prevailing circumstance. The key facts in this circumstance are that providing treatment (which is saving identified lives), involves mostly providing palliative treatment, which is associated with a high likelihood of death among the identified lives while undergoing treatment or shortly thereafter. I focus on the dilemma of having a national cancer prevention program versus the expansion of cancer treatment facilities.
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Brindley C, Lomas J, Siciliani L. The effect of hospital spending on waiting times. Health Econ 2023; 32:2427-2445. [PMID: 37424194 DOI: 10.1002/hec.4735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/03/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023]
Abstract
Long waiting times have been a persistent policy issue in the United Kingdom that the COVID-19 pandemic has exacerbated. This study analyses the causal effect of hospital spending on waiting times in England using a first-differences panel approach and an instrumental variable strategy to deal with residual concerns for endogeneity. We use data from 2014 to 2019 on waiting times from general practitioner referral to treatment (RTT) measured at the level of local purchasers (known as Clinical Commissioning Groups). We find that increases in hospital spending by local purchasers of 1% reduce median RTT waiting time for patients whose pathway ends with a hospital admission (admitted pathway) by 0.6 days but the effect is not statistically significant at 5% level (only at the 10% level). We also find that higher hospital spending does not affect the RTT waiting time for patients whose pathway ends with a specialist consultation (non-admitted pathway). Nor does higher spending have a statistically significant effect on the volume of elective activity for either pathway. Our findings suggest that higher spending is no guarantee of higher volumes and lower waiting times, and that additional mechanisms need to be put in place to ensure that increased spending benefits elective patients.
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Affiliation(s)
- Callum Brindley
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - James Lomas
- Centre for Health Economics, University of York, York, UK
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, UK
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Baumann MF, Maria M. Improving access to prosthetic limbs in Germany: An explorative review. Prosthet Orthot Int 2023; 47:486-493. [PMID: 37615611 PMCID: PMC10561679 DOI: 10.1097/pxr.0000000000000254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/20/2023] [Accepted: 06/09/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Meeting the needs of users when it comes to accessing prosthetic limbs is an important factor in the acceptance and use of a prosthesis; the cost of such prosthetics also constitutes a potential financial challenge. OBJECTIVES The aim of this study was to investigate potential hurdles to accessing limb prosthetics in the German health care system, including organizational, social, economic, and regulatory issues, and to provide food for thought about ethical implications. METHODS Sixteen German users of limb prosthetics with upper-limb and/or lower-limb amputation were recruited by means of purposive sampling. Semistructured interviews were performed, with the guiding question being as follows: "What were your experiences with the German prosthetic care and reimbursement system?" Ten stakeholders (insurance representatives, prosthetic technicians, medical service representatives, a law expert, and a lawyer) were asked about the issues they encounter in their work related to prosthetic care and reimbursement, and about ways to ameliorate these issues. A qualitative content analysis method was used to analyze the data. RESULTS Half of the interviewed service users experienced hurdles to gaining a suitable prosthetic device, such as waiting times and pressure to negotiate their need for a certain prosthesis. Some of the views expressed about the issues relating to prosthetic reimbursement in Germany were common to all stakeholders, whereas some conflicted with the views of others. CONCLUSIONS Equitable access to prostheses and the efficient distribution of prosthetic innovations could be improved by organizational and regulatory measures. Furthermore, a user-centered design of prostheses, a health technology assessment, monitoring of prosthetic care pathways, and a societal discussion about rationing in health care should be considered as parts of a broader approach to tackle this issue.
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Affiliation(s)
- Martina F Baumann
- Karlsruhe, Institute of Technology Assessment and Systems Analysis, Karlsruhe, Germany
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Abstract
Healthcare rationing has been the subject of numerous debates and concerns in the field of health economics in recent years. It is a concept which refers to the allocation of scarce healthcare resources and involves the use of different approaches to the delivery of health services and patient care. Regardless of the approach used, healthcare rationing fundamentally involves withholding potentially beneficial programs and/or treatments from certain people. As the demands placed on health services continue to rise and with that significant increases to the cost, healthcare rationing has become increasingly popular and is deemed necessary for the delivery of affordable, patient-care services. However, public discourse on this issue has largely been centered on ethical considerations with less focus on economic rationality. Establishing the economic rationality of healthcare rationing is essential in healthcare decision-making and consideration of its adoption by healthcare authorities and organizations. This scoping review of seven articles demonstrates that the economic rationality of healthcare rationing is the scarcity of healthcare resources amidst increased demand and costs. Therefore, supply, demand, and benefits are at the core of healthcare rationing practices and influence decisions on its suitability. Given the increased costs of care and resource scarcity, healthcare rationing is a suitable practice towards ensuring healthcare resources are allocated to people in a rational, equitable, and cost-effective manner. The rising costs and demands for care place significant pressure on healthcare authorities to identify suitable strategies for the allocation of healthcare resources. Healthcare rationing as a priority-setting strategy would support healthcare authorities identify mechanisms to allocate scarce resources in a cost-effective manner. When used in the context of a priority-setting approach, healthcare rationing helps healthcare organizations and practitioners to ensure that patient populations achieve maximum benefits at reasonable costs. It represents a fair allocation of healthcare resources to all populations, especially in low-income settings.
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Affiliation(s)
- Jakub Berezowski
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
- Group of Research in Care (GRUPAC), Faculty of Health Science, University of La Rioja, Logroño, Spain
| | - Stanisław Manulik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Catherine Ross
- The Centre for Cardiovascular Health, School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom
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Wadmann S, Hauge AM, Emdal Navne L. Good conduct in a context of rationing: A case study of how frontline professionals deal with distributive dilemmas of novel gene therapies. Sociol Health Illn 2023; 45:684-704. [PMID: 36633956 DOI: 10.1111/1467-9566.13608] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Classical dilemmas of how to distribute limited resources have been rekindled by the rise of advanced, high-cost therapies. Building on a case study of a novel gene therapy in neuropaediatric care, this article explores the dilemmas that explicit priority setting can create for frontline professionals and develops a typology of professionals' responses to these dilemmas. Despite political attempts to centralise priority setting and spare health professionals from having to consider treatment costs at the 'bedside', this study shows that concern for economic efficiency and budget control nonetheless need to be handled and balanced against other accountabilities in the daily work of frontline professionals. Contributing to the sociological debate on priority setting and rationing, this study develops an analytical perspective attuned to the relational aspects of frontline work and the challenges related to the balancing of diverging ideas of good conduct. Further, focussing on an empirical field at the forefront of genomic medicine, this study brings the sociological debate on priority setting and rationing up to date with current developments in precision medicine.
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Affiliation(s)
- Sarah Wadmann
- VIVE-The Danish Center for Social Science Research, Copenhagen, Denmark
| | | | - Laura Emdal Navne
- VIVE-The Danish Center for Social Science Research, Copenhagen, Denmark
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Holm S, Warrington DJ. Frailty as a Priority-Setting Criterion for Potentially Lifesaving Treatment-Self-Fulfilling Prophecy, Circularity, and Indirect Discrimination? Camb Q Healthc Ethics 2023; 32:48-55. [PMID: 36419320 DOI: 10.1017/S0963180122000494] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event. Frailty is most frequently assessed in the old using the Clinical Frailty Scale (CSF) which ranks frailty from 1 to 9. This assessment typically takes less than one minute and is not validated in patients with learning difficulties or those under 65 years old. The National Institute for Health and Care Excellence (NICE) developed guidelines that use "frailty" as one of the priority-setting criteria for how scarce, but potentially lifesaving, health care resources should be allocated during the COVID-19 pandemic. Similar guidelines have been developed elsewhere. This paper discusses the ethical implications of such rationing and argues that this is an unproven and ethically problematic form of health care rationing. It specifically discusses: (1) how the frailty ascription becomes a self-fulfilling prophecy, (2) the problematic use of "frailty" in COVID-19 "triage," (3) the circularity of the link between age and frailty, (4) indirect discrimination because of the use of a seemingly neutral criterion in health care rationing, and (5) the difficult link between comorbidities and frailty. It is found that there was no research into the use of global frailty scores as a criterion for access to acute treatment before January 2020 and so it is concerning how readily frailty scoring has been adopted to ration access to potentially lifesaving treatments. Existing gerontological frailty scoring systems have not been developed for this purpose, and repurposing them creates significant ethical issues.
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Alós-Ferrer C, García-Segarra J, Ginés-Vilar M. Ethical allocation of scarce vaccine doses: The Priority-Equality protocol. Front Public Health 2022; 10:986776. [PMID: 36582371 PMCID: PMC9792380 DOI: 10.3389/fpubh.2022.986776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/17/2022] [Indexed: 12/15/2022] Open
Abstract
Background Whenever vaccines for a new pandemic or widespread epidemic are developed, demand greatly exceeds the available supply of vaccine doses in the crucial, initial phases of vaccination. Rationing protocols must then fulfill a number of ethical principles balancing equal treatment of individuals and prioritization of at-risk and instrumental subpopulations. For COVID-19, actual rationing methods used a territory-based first allocation stage based on proportionality to population size, followed by locally-implemented prioritization rules. The results of this procedure have been argued to be ethically problematic. Methods We use a formal-analytical approach arising from the mathematical social sciences which allows to investigate whether any allocation methods (known or unknown) fulfill a combination of (ethical) desiderata and, if so, how they are formulated algorithmically. Results Strikingly, we find that there exists one and only one method that allows to treat people equally while giving priority to those who are worse off. We identify this method down to the algorithmic level and show that it is easily implementable and it exhibits additional, desirable properties. In contrast, we show that the procedures used during the COVID-19 pandemic violate both principles. Conclusions Our research delivers an actual algorithm that is readily applicable and improves upon previous ones. Since our axiomatic approach shows that any other algorithm would either fail to treat people equally or fail to prioritize those who are worse off, we conclude that ethical principles dictate the adoption of this algorithm as a standard for the COVID-19 or any other comparable vaccination campaigns.
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Affiliation(s)
- Carlos Alós-Ferrer
- Zurich Center for Neuroeconomics, University of Zurich, Zurich, Switzerland,*Correspondence: Carlos Alós-Ferrer
| | | | - Miguel Ginés-Vilar
- Department of Economics, Universitat Jaume I, Castellón de la Plana, Spain
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10
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White J, Corwin N. Insulin Shocks. J Health Polit Policy Law 2022; 47:731-753. [PMID: 35867535 DOI: 10.1215/03616878-10041149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Some of the news about insulin is shocking. In the United States, people have died because they were rationing a life-saving medication discovered in the 1920s. How could this happen? Perhaps a better question is why anyone should be surprised. The insulin story both illustrates and challenges many understandings of the problems with insurance, treatment, payment, and politics in the US health care system. It particularly highlights consequences of structuring price discounts as rebates to health plans or government instead of as lower individual prices to patients. Perversely, this encourages higher list prices, which, for patients without insurance or with high cost sharing, make insulin less affordable than it would be without the rebates.
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Radosz-Knawa Z, Kamińska A, Malinowska-Lipień I, Brzostek T, Gniadek A. Factors Influencing the Rationing of Nursing Care in Selected Polish Hospitals. Healthcare (Basel) 2022; 10. [PMID: 36360531 DOI: 10.3390/healthcare10112190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/12/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction: The rationalization of nursing care can be a direct consequence of the low employment rate or unfavorable working environment of nurses. Aim: The aim of the study was to learn about the factors influencing the rationing of nursing care. Methods: The study group consisted of 209 nurses working in internal medicine departments. The study used the method of a diagnostic survey, a survey technique with the use of research tools: the BERNCA-R questionnaire and the PES-NWI questionnaire (which includes the occupational burnout questionnaire). Results: The mean total BERNCA score for rationing nursing care was 1.94 ± 0.75 on a scale from 0 to 4. A statistically significant relationship was demonstrated between the work environment and the rationing of nursing care. The results of the BERNCA-R scale correlated statistically significantly and positively (r > 0) with two (out of three) subscales of the occupational burnout questionnaire (MBI—Maslach Burnout Inventory): emotional exhaustion and depersonalization (p < 0.001), and with all types of adverse events analyzed (p < 0.05). Conclusions: The higher the frequency of care rationing, the worse the assessment of working conditions by nurses, and, therefore, more frequent care rationing determined the more frequent occurrence of adverse events. The more frequent the care rationing, the more frequent adverse events occur.
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Bermudez GF, Prah JJ. Examining power dynamics in global health governance using topic modeling and network analysis of Twitter data. BMJ Open 2022; 12:e054470. [PMID: 35667718 PMCID: PMC9171232 DOI: 10.1136/bmjopen-2021-054470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite increases in global health actors and funding levels, health inequities persist. We empirically tested whether global health governance (GHG) operates under the rational actor model (RAM) and characterised GHG power dynamics. DESIGN We collected approximately 75 000 tweets of 20 key global health actors, between 2016 and 2020, using Twitter API. We generated priorities from tweets collected using topic modelling. Priorities from tweets were compared with stated priorities from content analyses of policy documents and with revealed priorities from network analyses of development assistance for health funding data. Comparing priorities derived from Twitter, policy documents and funding data, we can test whether GHG operates under RAM and characterise power dynamics in GHG. PARTICIPANTS 20 global health actors were identified based on a consensus of three peer-reviewed articles mapping global health networks. All tweets of each actor were collected in 3-month intervals from November 2016 to May 2020. Policy documents and developmental assistance for health (DAH) financial data for each actor were collected for the same period. RESULTS We find all 20 actors and the global health system collectively fulfil the three conditions of RAM based on stated and revealed priorities. We also find compulsory and institutional power asymmetries in GHG. Funding organisations have compulsory power over channels of DAH and implementing institutions they directly fund. Funding organisations also have transitive influence over implementing institutions receiving DAH funding. CONCLUSIONS We find that there is a correlation between the priorities of large funders and the priorities of health actors. This correlation in conjunction with GHG operating under the RAM and the asymmetric power held by funders raises issues. GHG under the RAM grants large funders majority of the power to determine global health priorities and ultimately influencing outcomes while implementing organisations, especially those that work closest with populations, have little to limited influence in priority-setting.
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Affiliation(s)
- Gian Franco Bermudez
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer J Prah
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Schaefer GO, Muralidharan A. Necessity, Rights, and Rationing in Compulsory Research. Hastings Cent Rep 2022; 52:31-33. [PMID: 35763206 DOI: 10.1002/hast.1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In "Compulsory Research in Learning Health Care: Against a Minimal Risk Limit," Robert Steel offers an argument in favor of compelling individuals to participate in some research that poses more than minimal risk. In his view, the ethics of compulsory research turns on questions of fair distribution of benefits and burdens, within a paradigm analogous to health care resource rationing. We do not dispute that it may theoretically be permissible to compel participation in certain circumstances, including those that rise above minimal risk. Nevertheless, Steel's argument for this conclusion faces several challenges that ultimately render it unconvincing in its present form. First, compulsion should be subject to a "necessity" criterion, which substantially limits its applicable scope. Second, compulsion is a prima facie rights violation that requires stronger ethical justification than Steel offers. And third, substantial structural and motivational differences between rationing and compulsion render the analogy inapt.
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Ryan MA. Tragic Choices, Revisited: COVID-19 and the Hidden Ethics of Rationing. Christ Bioeth 2022; 28:58-75. [PMID: 35432574 PMCID: PMC8992335 DOI: 10.1093/cb/cbab019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Early in the COVID-19 pandemic in the United States, concern that there could be a shortage of ventilators raised the possibility of rationing care. Denying patients life-saving care captures our moral imagination, prompting the demand for a defensible framework of ethical principles for determining who will live and who will die. Behind the moral dilemma posed by the shortage of a particular medical good lies a broad moral geography encompassing important and often unarticulated societal values, as well as assumptions about the nature and purpose of health care and the consequences of long-standing choices about health care as a social good. This article explores what COVID-19 has exposed concerning values and choices around health care in the United States. Employing the lens of Catholic Social Thought, it argues for an approach to rationing that is grounded in respect for human dignity, committed to distributing social goods in light of the common good, and self-conscious about the construction of vulnerability to illness and death.
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Affiliation(s)
- Maura A Ryan
- University of Notre Dame, Notre Dame, Indiana, USA
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15
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Iltis A. (Re)-Emerging Challenges in Christian Bioethics: Leading Voices in Christian Bioethics. Christ Bioeth 2022; 28:1-10. [PMID: 35992505 PMCID: PMC9383548 DOI: 10.1093/cb/cbab017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This is the third installment in a Christian Bioethics series that gathers leading voices in Christian bioethics to examine the themes and issues they find most pressing. The papers address fundamental theoretical questions about the nature of Christian bioethics itself, long-standing ethical issues that remain significant today, including physician-assisted suicide, euthanasia, the definition of death, the allocation of scarce resources, and finally, more futuristic questions regarding transhumanism. The contributions underscore the enduring significance of Christian engagement in bioethics.
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Affiliation(s)
- Ana Iltis
- Wake Forest University, Winston-Salem, North Carolina,USA
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Vincent JL. Ethical Lessons from an Intensivist's Perspective. J Clin Med 2022; 11:1613. [PMID: 35329939 DOI: 10.3390/jcm11061613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022] Open
Abstract
Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised ethical dilemmas as physicians have had to determine how best to allocate the sparse resources. Here, we reflect on some of the major ethical aspects of the COVID-19 pandemic, including resource allocation and rationing, end-of-life decision-making, and communication and staff support. Importantly, these issues are regularly faced in non-pandemic ICU patient management and useful lessons can be learned from the discussions that have occurred as a result of the COVID-19 situation.
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Cuartas PA, Tavares Santos H, Levy BM, Gong MN, Powell T, Chuang E. Modeling Outcomes Using Sequential Organ Failure Assessment (SOFA) Score-Based Ventilator Triage Guidelines During the COVID-19 Pandemic. Disaster Med Public Health Prep 2022; 17:e128. [PMID: 35152936 DOI: 10.1017/dmp.2022.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To model performance of the Sequential Organ Failure Assessment (SOFA) score-based ventilator allocation guidelines during the COVID-19 pandemic. METHODS A retrospective cohort study design was used. Study sites included 3 New York City hospitals in a single academic medical center. We included a random sample (205) of adult patients who were intubated (1002) from March 25, 2020, till April 29, 2020. Protocol criteria adapted from the New York State's 2015 guidelines were applied to determine which patients would have had mechanical ventilation withheld or withdrawn. RESULTS 117 (57%) patients would have been identified for ventilator withdrawal or withholding based on the triage guidelines. Of those 117 patients, 28 (24%) survived hospitalization. Overall, 65 (32%) patients survived to discharge. CONCLUSION Triage protocols aim to maximize survival by redirecting ventilators to those most likely to survive. Over 50% of this sample would have been identified as candidates for ventilator exclusion. Clinical judgment would therefore still be needed in ventilator reallocation, thus re-introducing bias and moral distress. This data suggests limited utility for SOFA score-based ventilator rationing. It raises the question of whether there is sufficient ethical justification to impose a life-ending decision based on a SOFA scoring method on some patients in order to offer potential benefit to a modest number of others.
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Rovira C, Modamio P, Pascual J, Armengol J, Ayala C, Gallego J, Mariño EL, Ramirez A. Person-centred care provided by a multidisciplinary primary care team to improve therapeutic adequacy in polymedicated elderly patients (PCMR): randomised controlled trial protocol. BMJ Open 2022; 12:e051238. [PMID: 35140146 PMCID: PMC8830237 DOI: 10.1136/bmjopen-2021-051238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION The increase in elderly population has led to an associated increase in multiple pathologies, frailty, polypharmacy, healthcare costs, decreased quality of life and mortality. We designed an intervention based on person-centred care model. This article outlines a study protocol, which aims to explore the effects of the intervention to improve therapeutic adequacy in polymedicated elderly patients. METHODS AND ANALYSIS An open, randomised, multicentre, controlled clinical trial. The study population includes polymedicated (≥8 prescription medications) patients ≥75 years old. In the intervention group, the multidisciplinary team (primary care pharmacist, family doctor and nurse) will meet to carry out multidimensional reviews (frailty, clinical complexity, morbidity and therapeutic adequacy) of the study subjects. If changes are proposed to the treatment plan, a clinical interview will be conducted with the patient to agree on changes in accordance with their preferences. Follow-up visits will be scheduled at 6 and 12 months. In the control group, where the usual clinical practice will be followed, the necessary data will be collected to compare the results.The key variables are the variation in the mean number of incidents (potentially inappropriate prescription) per patient, the number of medications, the number of changes implemented to the treatment plan and the variation in the number of hospital admissions. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of the IDIAPJGol and by the University of Barcelona's Bioethics Commission. The results are expected to be published in peer reviewed open-access journals, and as part of a doctoral thesis. TRIAL REGISTRATION NUMBER NCT04188470. Pre-results.
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Affiliation(s)
- Carol Rovira
- Clinical Pharmacy and Pharmaceutical Care Unit. Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry. Faculty of Pharmacy and Food Sciences, Universitat de Barcelona, Barcelona, Spain
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
| | - Pilar Modamio
- Clinical Pharmacy and Pharmaceutical Care Unit. Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry. Faculty of Pharmacy and Food Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Joaquim Pascual
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
| | - Joan Armengol
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
| | - Cristian Ayala
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
| | - Joan Gallego
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
| | - Eduardo L Mariño
- Clinical Pharmacy and Pharmaceutical Care Unit. Department of Pharmacy and Pharmaceutical Technology, and Physical Chemistry. Faculty of Pharmacy and Food Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Anna Ramirez
- Bages-Berguedà-Moianès Primary Healthcare Service, Institut Catala De La Salut, Barcelona, Spain
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19
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Sandal S, Massie A, Boyarsky B, Chiang TPY, Thavorn K, Segev DL, Cantarovich M. Impact of the COVID-19 pandemic on transplantation by income level and cumulative COVID-19 incidence: a multinational survey study. BMJ Open 2022; 12:e055367. [PMID: 35022176 PMCID: PMC8756076 DOI: 10.1136/bmjopen-2021-055367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic significantly affected the provisions of health services to necessary but deprioritised fields, such as transplantation. Many programmes had to ramp-down their activity, which may significantly affect transplant volumes. We aimed to pragmatically analyse measures of transplant activity and compare them by a country's income level and cumulative COVID-19 incidence (CCI). DESIGN, SETTING AND PARTICIPANTS From June to September 2020, we surveyed transplant physicians identified as key informants in their programmes. Of the 1267 eligible physicians, 40.5% from 71 countries participated. OUTCOME Four pragmatic measures of transplant activity. RESULTS Overall, 46.5% of the programmes from high-income countries anticipate being able to maintain >75% of their transplant volume compared with 31.6% of the programmes from upper-middle-income countries, and with 21.7% from low/lower-middle-income countries (p<0.001). This could be because more programmes in high-income countries reported being able to perform transplantation/s (86.8%%-58.5%-67.9%, p<0.001), maintain prepandemic deceased donor offers (31.0%%-14.2%-26.4%, p<0.01) and avoid a ramp down phase (30.9%%-19.7%-8.3%, p<0.001), respectively. In a multivariable analysis that adjusted for CCI, programmes in upper-middle-income countries (adjusted OR, aOR=0.47, 95% CI 0.27 to 0.81) and low/lower-middle-income countries (aOR 0.33, 95% CI 0.16 to 0.67) had lower odds of being able to maintain >75% of their transplant volume, compared with programmes in high-income countries. Again, this could be attributed to lower-income being associated with 3.3-3.9 higher odds of performing no transplantation/s, 66%-68% lower odds of maintaining prepandemic donor offers and 37%-76% lower odds of avoiding ramp-down of transplantation. Overall, CCI was not associated with these measures. CONCLUSIONS The impact of the pandemic on transplantation was more in lower-income countries, independent of the COVID-19 burden. Given the lag of 1-2 years in objective data being reported by global registries, our findings may inform practice and policy. Transplant programmes in lower-income countries may need more effort to rebuild disrupted services and recuperate from the pandemic even if their COVID-19 burden was low.
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Affiliation(s)
- Shaifali Sandal
- Department of Medicine, Division of Nephrology, Multi-organ Transplant Program, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Allan Massie
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Brian Boyarsky
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Kednapa Thavorn
- Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcelo Cantarovich
- Department of Medicine, Division of Nephrology, Multi-organ Transplant Program, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
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20
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Tinghög G, Strand L. Public Attitudes Toward Priority Setting Principles in Health Care During COVID-19. Front Health Serv 2022; 2:886508. [PMID: 36925871 PMCID: PMC10012618 DOI: 10.3389/frhs.2022.886508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022]
Abstract
What role should cost-effectiveness play in health care priority setting? We assess the level of acceptance toward different priority setting principles in health care during COVID-19 and in general, thereby exploring public support for principles presented at different levels of abstraction. An online survey was distributed to a diverse sample of the Swedish population (n = 1 553). The results show that respondents were generally more supportive of priority setting principles when expressed in general abstract terms than when expressed in more case specific concrete terms. However, prioritization based on cost-effectiveness was deemed as more acceptable when expressed in concrete terms related to health maximization rather than as an abstract principle. Respondents had a general inclination in support of physicians and other health care professionals the primary responsibility for the allocation of scarce resources in the healthcare during COVID-19, while being less supportive of health economists and politicians being involved in these decisions.
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Affiliation(s)
- Gustav Tinghög
- Swedish National Centre for Priority Setting in Health Care, Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Management and Engineering, Linköping University, Linköping, Sweden
| | - Liam Strand
- Swedish National Centre for Priority Setting in Health Care, Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
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21
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Abstract
According to the widely accepted principles of beneficence and distributive justice, I argue that healthcare providers and facilities have an ethical duty to reduce the ecological footprint of the services they provide. I also address the question of whether the reductions in footprint need or should be patient-facing. I review Andrew Jameton and Jessica Pierce's claim that achieving ecological sustainability in the healthcare sector requires rationing the treatment options offered to patients. I present a number of reasons to think that we should not ration health care to achieve sufficient reductions in a society's overall consumption of ecological goods. Moreover, given the complexities of ecological rationing, I argue that there are good reasons to think that the ethical duty to reduce the ecological footprint of health care should focus on only nonpatient-facing changes. I review a number of case studies of hospitals who have successfully retrofitted facilities to make them more efficient and reduced their resource and waste streams.
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Affiliation(s)
- Corey Katz
- Georgian Court University, Lakewood, New Jersey, USA
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22
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Cameron J, Stewart C, Savulescu J. Assessing Rationing Decisions through the Principle of Proportionality. J Law Med 2021; 28:955-964. [PMID: 34907679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Rationing policies necessarily discriminate, as they must identify bases on which to discriminate between patients in order to prioritise. Treatments may provide a greater benefit to some people than others and this may be a morally relevant difference that justifies discrimination. But it is difficult to identify when a reduced capacity to benefit from treatment is a sufficient basis deny a person access to treatment. We argue that a clearer test is required to hold governments to account. Discriminatory policies should be assessed by incorporating the principle of utility into the proportionality test. This would mean that discriminatory policies could only be justified if the benefit to the community in discriminating outweighed the cost to the individual of being discriminated against.
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Affiliation(s)
| | | | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics and Wellcome Centre for Ethics and Humanities, University of Oxford
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23
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Dieteren CM, Reckers-Droog VT, Schrama S, de Boer D, van Exel J. Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting. Health Expect 2021; 25:333-344. [PMID: 34845790 PMCID: PMC8849370 DOI: 10.1111/hex.13385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/10/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022] Open
Abstract
Context It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle‐related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands. Methods We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints. Findings We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost‐effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public. Conclusions This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion—in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.
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Affiliation(s)
- Charlotte M Dieteren
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Vivian T Reckers-Droog
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Sara Schrama
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Dynothra de Boer
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
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24
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Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
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25
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Brown SD, Hardy SM, Bruno MA. Rationing and Disparities in Health Care: Implications for Radiology Clinical Practice Guidelines. J Am Coll Radiol 2021; 19:84-89. [PMID: 34687667 DOI: 10.1016/j.jacr.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/26/2022]
Abstract
We examine the relationship between the rationing of health care resources and disparities in health care delivery and the specific implications for radiologic resource allocation frameworks such as the ACR Appropriateness Criteria. We explore what rationing is in this context and how it is manifested in radiology. We review how rationing has taken many forms and how rationing has influenced the development of disparities in access and outcomes within health care and specifically within the context of radiology. We describe how the relationship between rationing and health care delivery disparities manifested during the coronavirus disease 2019 pandemic and the corrective measures that were proposed to established rationing frameworks to facilitate more equitable pandemic-related resource distribution. We offer suggestions regarding how such solutions might be brought into radiologic resource allocation schemes to help mitigate disparities in radiologic care in the future.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts; and Center for Bioethics, Harvard Medical School, Boston, Massachusetts.
| | - Seth M Hardy
- Department of Radiology, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Michael A Bruno
- Vice-Chair, Quality and Chief, Emergency Radiology, The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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26
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Hamilton CB, Dehnadi M, Snow ME, Clark N, Lui M, McLean J, Mamdani H, Kooijman AL, Bubber V, Hoefer T, Li LC. Themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making in healthcare systems: a scoping review. BMJ Open 2021; 11:e050208. [PMID: 34635521 PMCID: PMC8506891 DOI: 10.1136/bmjopen-2021-050208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To identify the key themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making across the organisation and system domains of healthcare systems. METHODS We conducted a scoping review. Seven databases of journal articles were searched from their inception to June 2019. Eligible articles were literature reviews published in English and provided useful information for determining aspects of engaging patients and family caregivers in decision-making to evaluate. We extracted text under three predetermined categories: structure, process and outcomes that were adapted from the Donabedian conceptual framework. These excerpts were then independently open-coded among four researchers. The subsequent themes and their corresponding excerpts were summarised to provide a rich description of each theme. RESULTS Of 7747 unique articles identified, 366 were potentially relevant, from which we selected the 42 literature reviews. 18 unique themes were identified across the three predetermined categories. There were six structure themes: engagement plan, level of engagement, time and timing of engagement, format and composition, commitment to support and environment. There were four process themes: objectives, engagement approach, communication and engagement activities. There were eight outcome themes: decision-making process, stakeholder relationship, capacity development, stakeholder experience, shape policy/service/programme, health status, healthcare quality, and cost-effectiveness. CONCLUSIONS The 18 themes and their descriptions provide a foundation for identifying constructs and selecting measures to evaluate the quality of initiatives for engaging patients and family caregivers in healthcare system decision-making within the organisation and system domains. The themes can be used to investigate the mechanisms through which relevant initiatives are effective and investigate their effectiveness.
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Affiliation(s)
- Clayon B Hamilton
- Evaluation and Research Services, Fraser Health Authority, Surrey, British Columbia, Canada
- Primary Care Division, Ministry of Health, Victoria, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maryam Dehnadi
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - M Elizabeth Snow
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Nancy Clark
- Faculty of Human and Social Development, University of Victoria, Victoria, British Columbia, Canada
| | - Michelle Lui
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Janet McLean
- Family Caregivers of British Columbia, Victoria, British Columbia, Canada
| | - Hussein Mamdani
- Arthritis Research Canada, Vancouver, British Columbia, Canada
| | - Allison L Kooijman
- Patient Voices Network, BC Patient Safety and Quality Council, Vancouver, British Columbia, Canada
- School of Interdisciplinary Studies, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vikram Bubber
- Patient Voices Network, BC Patient Safety and Quality Council, Vancouver, British Columbia, Canada
| | - Tammy Hoefer
- BC Patient Safety and Quality Council, Vancouver, British Columbia, Canada
| | - Linda C Li
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
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27
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Ariyo K, Canestrini S, David AS, Ruck Keene A, Wolfrum S, Owen G. Quality of life in elderly ICU survivors before the COVID-19 pandemic: a systematic review and meta-analysis of cohort studies. BMJ Open 2021; 11:e045086. [PMID: 34635510 PMCID: PMC8506050 DOI: 10.1136/bmjopen-2020-045086] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 07/20/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES The influence of age on intensive care unit (ICU) decision-making is complex, and it is unclear if it is based on expected subjective or objective patient outcomes. To address recent concerns over age-based ICU decision-making, we explored patient-assessed quality of life (QoL) in ICU survivors before the COVID-19 pandemic. DESIGN A systematic review and meta-analysis of cohort studies published between January 2000 and April 2020, of elderly patients admitted to ICUs. PRIMARY AND SECONDARY OUTCOME MEASURES We extracted data on self-reported QoL (EQ-5D composite score), demographic and clinical variables. Using a random-effect meta-analysis, we then compared QoL scores at follow-up to scores either before admission, age-matched population controls or younger ICU survivors. We conducted sensitivity analyses to study heterogeneity and bias and a qualitative synthesis of subscores. RESULTS We identified 2536 studies and included 22 for qualitative synthesis and 18 for meta-analysis (n=2326 elderly survivors). Elderly survivors' QoL was significantly worse than younger ICU survivors, with a small-to-medium effect size (d=0.35 (-0.53 and -0.16)). Elderly survivors' QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (-0.44 and -0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (-0.43 and 0.00)). Mortality rates and length of follow-up partly explained heterogeneity. Reductions in QoL seemed primarily due to physical health, rather than mental health items. CONCLUSIONS The results suggest that the proportionality of age as a determinant of ICU resource allocation should be kept under close review and that subjective QoL outcomes should inform person-centred decision -aking in elderly ICU patients. PROSPERO REGISTRATION NUMBER CRD42020181181.
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Affiliation(s)
- Kevin Ariyo
- Department of Psychological Medicine, King's College London, London, UK
| | - Sergio Canestrini
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Alex Ruck Keene
- Department of Psychological Medicine, King's College London, London, UK
- Dickson Poon School of Law, King's College London, London, UK
| | - Sebastian Wolfrum
- Medical Clinic II, Cardiology/Angiology/Intensive Care Medicine, University Hospital Schleswig Holstein, Lübeck, Germany
- Department of Emergency Medicine, University Hospital Schleswig Holstein, Lübeck, Germany
| | - Gareth Owen
- Department of Psychological Medicine, King's College London, London, UK
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28
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Taylor A, Feuvre DL, Taylor B. COVID-19: The South African experience. Interv Neuroradiol 2021; 27:50-53. [PMID: 34668794 PMCID: PMC8579359 DOI: 10.1177/15910199211035905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 11/15/2022] Open
Abstract
The coronavirus disease-2019 pandemic affected the countries differently. South Africa is a middle-income country with a struggling economy and a resource-constrained public healthcare system. Three aspects of the pandemic in South Africa are examined, the lockdown and its effect on personal freedoms, how health care resources were used and the novel stratification of health workers into vulnerability categories. It is a perspective written after experiencing the first pandemic peak in 2020.
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Affiliation(s)
- Allan Taylor
- Division of Neurosurgery, University of Cape Town, South Africa
| | - David Le Feuvre
- Division of Neurosurgery, University of Cape Town, South Africa
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29
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Scire E, Jeong KY, Gaurke M, Prusak B, Sulmasy DP. Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans. Chest 2021; 161:504-513. [PMID: 34506791 PMCID: PMC8423769 DOI: 10.1016/j.chest.2021.08.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/10/2021] [Accepted: 08/31/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.
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Affiliation(s)
- Emily Scire
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Bernard Prusak
- Department of Philosophy and McGowan Center for Ethics and Social Responsibility, King's College, Wilkes-Barre, PA
| | - Daniel P Sulmasy
- School of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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30
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Abstract
One way to compare health care needs and outcomes on common scales is by estimating the strength of preferences or willingness-to-pay (WTP). The aim of this study was to review directly measured preference values and WTP estimates for health states treated by plastic surgery. The included articles had to meet the criteria defined in the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type). Relevant databases were searched using predetermined strings. Data were extracted in a standardised manner. Included studies were appraised according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for rating the importance of outcomes. In total, 213 abstracts were retrieved. Of these, 179 did not meet the inclusion criteria and were excluded, leaving 34 studies in the review. The risk of bias was considered moderate in four studies and serious in the rest. The overall certainty of evidence for directly measured preference values and WTP estimates for health states treated by plastic surgery is low (Grade ƟƟОО). The lowest preference scores were generally elicited for facial defects/anomalies and the highest for excess skin after massive weight loss. Scientific knowledge about preferences and the resulting health gains might play an essential role in deciding which procedures should be considered for public funding or rather rationed within the system. Better quality studies are required to allow for such applications.
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Affiliation(s)
- Emma Hansson
- Department of Plastic and Reconstructive Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Sciences, The Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Lars Sandman
- National Centre for Priorities in Health, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Västra Götaland Region, Gothenburg, Sweden.,Faculty of Police Work, Department of Campus Police Education, Borås University, Borås, Sweden
| | - Thomas Davidson
- National Centre for Priorities in Health, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Mansab F, Donnelly H, Kussner A, Neil J, Bhatti S, Goyal DK. Oxygen and Mortality in COVID-19 Pneumonia: A Comparative Analysis of Supplemental Oxygen Policies and Health Outcomes Across 26 Countries. Front Public Health 2021; 9:580585. [PMID: 34327182 PMCID: PMC8313806 DOI: 10.3389/fpubh.2021.580585] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 05/06/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Hypoxia is the main cause of morbidity and mortality in COVID-19. During the COVID-19 pandemic, some countries have reduced access to supplemental oxygen, whereas other nations have maintained and even improved access to supplemental oxygen. We examined whether variation in the nationally determined oxygen guidelines had any association with national mortality rates in COVID-19. Methods: Three independent investigators searched for, identified, and extracted the nationally recommended target oxygen levels for the commencement of oxygen in COVID-19 pneumonia from the 29 worst affected countries. Mortality estimates were calculated from three independent sources. We then applied both parametric (Pearson's R) and non-parametric (Kendall's Tau B) tests of bivariate association to determine the relationship between case fatality rate (CFR) and target SpO2, and also between potential confounders and CFR. Results: Of the 26 nations included, 15 had employed conservative oxygen strategies to manage COVID-19 pneumonia. Of them, Belgium, France, USA, Canada, China, Germany, Mexico, Spain, Sweden, and the UK guidelines advised commencing oxygen when oxygen saturations (SpO2) fell to 91% or less. A statistically significant correlation was found between SpO2 and CFR both parametrically (R = −0.53, P < 0.01) and non-parametrically (−0.474, P < 0.01). Conclusion: Our study highlights the disparity in oxygen provision for COVID-19 patients between the nations analysed. In those nations that pursued a conservative oxygen strategy, there was an association with higher national mortality rates. We discuss the potential reasons for such an association.
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Affiliation(s)
- Fatma Mansab
- COVID-19 Public Health Team, Public Health Gibraltar, Gibraltar, Gibraltar.,Postgraduate School of Medicine, University of Gibraltar, Gibraltar, Gibraltar
| | - Harry Donnelly
- Acute General Medicine, St Bernard's Hospital, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Albrecht Kussner
- Emergency Medicine, St Bernard's Hospital, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - James Neil
- Centre for Nutrition Education and Lifestyle Management (CNELM), London, United Kingdom
| | - Sohail Bhatti
- COVID-19 Public Health Team, Public Health Gibraltar, Gibraltar, Gibraltar.,Postgraduate School of Medicine, University of Gibraltar, Gibraltar, Gibraltar
| | - Daniel K Goyal
- COVID-19 Public Health Team, Public Health Gibraltar, Gibraltar, Gibraltar.,Acute General Medicine, St Bernard's Hospital, Gibraltar Health Authority, Gibraltar, Gibraltar.,Clinical Lecturer, Postgraduate School of Medicine, University of Gibraltar, Gibraltar, Gibraltar
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Weismann MF, Holder C. Ruthless Utilitarianism? COVID-19 State Triage Protocols May Subject Patients to Racial Discrimination and Providers to Legal Liability. Am J Law Med 2021; 47:264-290. [PMID: 34405783 DOI: 10.1017/amj.2021.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
As the coronavirus pandemic intensified, many communities in the United States experienced shortages of ventilators, intensive care beds, and other medical supplies and treatments. Currently, there is no single national response to provide guidance on allocation of scarce health care resources. Accordingly, states have formulated various "triage protocols" to prioritize those who will receive care and those who may not have the same access to health care services when the population demand exceeds the supply. Triage protocols address general concepts of "fairness" under accepted medical ethics rules and the consensus is that limited medical resources "should be allocated to do the greatest good for the greatest number of people."1 The actual utility of this utilitarian ethics approach is questionable, however, leaving many questions about what is "fair" unanswered. Saving as many people as possible during a health care crisis is a laudable goal but not at the expense of ignoring patients's legal rights, which are not suspended during the crisis. This Article examines the triage protocols from six states to determine whose rights are being recognized and whose rights are being denied, answering the pivotal question: If there is potential for disparate impact of facially neutral state triage protocols against Black Americans and other ethnic groups, is this legally actionable discrimination? This may be a case of first impression for the courts to resolve."[B]lack Americans are 3.5 times more likely to die of COVID-19 than [W]hite Americans … . Latinx people are almost twice as likely to die of the disease, compared with [W]hite people." 2 "Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism … . HHS is committed to leaving no one behind during an emergency, and this guidance is designed to help health care providers meet that goal." - Roger Severino, Office of Civil Rights Director, U.S. Department of Health and Human Services. 3.
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Abstract
OBJECTIVES Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN Population-based case-control study of adults who died. SETTING Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS Patients receiving palliative care under universal insurance with no user fees. EXPOSURE Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE Whether the patient received medical assistance in dying. RESULTS A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.
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Affiliation(s)
- Donald A Redelmeier
- Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kelvin Ng
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Psychology, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eldar Shafir
- Public Policy, Princeton University, Princeton, New Jersey, USA
- Psychology, Princeton University, Princeton, New Jersey, USA
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Incerti D, Rizzo S, Li X, Lindsay L, Yau V, Keebler D, Chia J, Tsai L. Prognostic model to identify and quantify risk factors for mortality among hospitalised patients with COVID-19 in the USA. BMJ Open 2021; 11:e047121. [PMID: 33827848 PMCID: PMC8029269 DOI: 10.1136/bmjopen-2020-047121] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/16/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To develop a prognostic model to identify and quantify risk factors for mortality among patients admitted to the hospital with COVID-19. DESIGN Retrospective cohort study. Patients were randomly assigned to either training (80%) or test (20%) sets. The training set was used to fit a multivariable logistic regression. Predictors were ranked using variable importance metrics. Models were assessed by C-indices, Brier scores and calibration plots in the test set. SETTING Optum de-identified COVID-19 Electronic Health Record dataset including over 700 hospitals and 7000 clinics in the USA. PARTICIPANTS 17 086 patients hospitalised with COVID-19 between 20 February 2020 and 5 June 2020. MAIN OUTCOME MEASURE All-cause mortality while hospitalised. RESULTS The full model that included information on demographics, comorbidities, laboratory results, and vital signs had good discrimination (C-index=0.87) and was well calibrated, with some overpredictions for the most at-risk patients. Results were similar on the training and test sets, suggesting that there was little overfitting. Age was the most important risk factor. The performance of models that included all demographics and comorbidities (C-index=0.79) was only slightly better than a model that only included age (C-index=0.76). Across the study period, predicted mortality was 1.3% for patients aged 18 years old, 8.9% for 55 years old and 28.7% for 85 years old. Predicted mortality across all ages declined over the study period from 22.4% by March to 14.0% by May. CONCLUSION Age was the most important predictor of all-cause mortality, although vital signs and laboratory results added considerable prognostic information, with oxygen saturation, temperature, respiratory rate, lactate dehydrogenase and white cell count being among the most important predictors. Demographic and comorbidity factors did not improve model performance appreciably. The full model had good discrimination and was reasonably well calibrated, suggesting that it may be useful for assessment of prognosis.
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Affiliation(s)
- Devin Incerti
- Product Development, Genentech, South San Francisco, California, USA
| | - Shemra Rizzo
- Product Development, Genentech, South San Francisco, California, USA
| | - Xiao Li
- Product Development, Genentech, South San Francisco, California, USA
| | - Lisa Lindsay
- Product Development, Genentech, South San Francisco, California, USA
| | - Vincent Yau
- Product Development, Genentech, South San Francisco, California, USA
| | - Dan Keebler
- Product Development, Genentech, South San Francisco, California, USA
| | - Jenny Chia
- Product Development, Genentech, South San Francisco, California, USA
| | - Larry Tsai
- Product Development, Genentech, South San Francisco, California, USA
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Abstract
OBJECTIVE The aim of the study was to understand the experiences of advanced practice nurses (APNs) in the UK during the 2020 COVID-19 pandemic, particularly in relation to safety, shortages and retention. DESIGN A cross-sectional, mixed-methods survey. SETTING APNs in any UK setting. PARTICIPANTS The survey was sent to an existing UK-wide cohort of APNs. 124 APNs responded (51%). RESULTS UK-based APNs in this study reported shortages of staff (51%) and personal protective equipment (PPE) (68%) during the first 3 months of the coronavirus outbreak. Almost half (47%) had considered leaving their job over the same 3 months. Despite difficulties, there were reports of positive changes to working practice that have enhanced care. CONCLUSION UK APNs report COVID-19-related shortages in staff and equipment across primary and secondary care and all regions of the UK. Shortages of PPE during a pandemic are known to be a factor in the development of mental health sequelae as well as a risk factor for increased turnover and retention issues. Half of APNs surveyed were considering a change in job. The UK risks a further crisis in staff morale and retention if this is not acknowledged and addressed. APNs also expressed concern about patients not receiving routine care as many specialties closed or reduced working during the crisis. However, there were also many examples of good practice, positive changes and innovation.
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Affiliation(s)
- Emily Wood
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Rachel King
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Michaela Senek
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Steve Robertson
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Bethany Taylor
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Angela Tod
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Anthony Ryan
- Health Sciences School, The University of Sheffield, Sheffield, South Yorkshire, UK
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Golder S, Bach M, O'Connor K, Gross R, Hennessy S, Gonzalez Hernandez G. Public Perspectives on Anti-Diabetic Drugs: Exploratory Analysis of Twitter Posts. JMIR Diabetes 2021; 6:e24681. [PMID: 33496671 PMCID: PMC7872831 DOI: 10.2196/24681] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/02/2020] [Accepted: 12/20/2020] [Indexed: 12/21/2022] Open
Abstract
Background Diabetes mellitus is a major global public health issue where self-management is critical to reducing disease burden. Social media has been a powerful tool to understand public perceptions. Public perception of the drugs used for the treatment of diabetes may be useful for orienting interventions to increase adherence. Objective The aim of this study was to explore the public perceptions of anti-diabetic drugs through the analysis of health-related tweets mentioning such medications. Methods This study uses an infoveillance social listening approach to monitor public discourse using Twitter data. We coded 4000 tweets from January 1, 2019 to October 1, 2019 containing key terms related to anti-diabetic drugs by using qualitative content analysis. Tweets were coded for whether they were truly about an anti-diabetic drug and whether they were health-related. Health-related tweets were further coded based on who was tweeting, which anti-diabetic drug was being tweeted about, and the content discussed in the tweet. The main outcome of the analysis was the themes identified by analyzing the content of health-related tweets on anti-diabetic drugs. Results We identified 1664 health-related tweets on 33 anti-diabetic drugs. A quarter (415/1664) of the tweets were confirmed to have been from people with diabetes, 17.9% (298/1664) from people posting about someone else, and 2.7% (45/1664) from health care professionals. However, the role of the tweeter was unidentifiable in two-thirds of the tweets. We identified 13 themes, with the health consequences of the cost of anti-diabetic drugs being the most extensively discussed, followed by the efficacy and availability. We also identified issues that patients may conceal from health care professionals, such as purchasing medications from unofficial sources. Conclusions This study uses an infoveillance approach using Twitter data to explore public perceptions related to anti-diabetic drugs. This analysis gives an insight into the real-life issues that an individual faces when taking anti-diabetic drugs, and such findings may be incorporated into health policies to improve compliance and efficacy. This study suggests that there is a fear of not having access to anti-diabetic drugs due to cost or physical availability and highlights the impact of the sacrifices made to access anti-diabetic drugs. Along with screening for diabetes-related health issues, health care professionals should also ask their patients about any non–health-related concerns regarding their anti-diabetic drugs. The positive tweets about dietary changes indicate that people with type 2 diabetes may be more open to self-management than what the health care professionals believe.
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Affiliation(s)
- Su Golder
- Department of Health Sciences, University of York, York, United Kingdom
| | - Millie Bach
- Department of Health Sciences, University of York, York, United Kingdom
| | - Karen O'Connor
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States
| | - Robert Gross
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States
| | - Graciela Gonzalez Hernandez
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA, United States
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Tai YL, Chi H, Chiu NC, Tseng CY, Huang YN, Lin CY. The Effect of a Name-Based Mask Rationing Plan in Taiwan on Public Anxiety Regarding a Mask Shortage During the COVID-19 Pandemic: Observational Study. JMIR Form Res 2021; 5:e21409. [PMID: 33400678 PMCID: PMC7837388 DOI: 10.2196/21409] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/17/2020] [Accepted: 12/24/2020] [Indexed: 12/21/2022] Open
Abstract
Background The COVID-19 pandemic is a severe global health crisis. Wearing a mask is a straightforward action that can be taken, but shortage of stock and equity of allocation were important issues in Taiwan. Furthermore, increased anxiety leading to the stockpiling of masks has been common during the pandemic. Objective We aim to summarize the name-based mask rationing plan implemented in Taiwan and explore the public’s perceived anxiety about mask shortages. Methods The government of Taiwan took action to control the supply and allocation of face masks. We summarize the timeline and important components of the mask rationing plan. A survey that aimed to investigate the overall response to the mask rationing plan was answered by 44 participants. Results The mask rationing plan was implemented in late January 2020. Daily production capacity was increased from 2 million masks to 16 million masks in April 2020. People could buy 9 masks in 14 days by verification via their National Health Insurance card. Digital face mask availability maps were created. Moreover, the mask plan safeguarded the purchase of masks and resulted in decreased anxiety about a mask shortage (4.05 [SD 1.15] points; 72.7% [n=32] of participants answered “agree” or “strongly agree”). The majority of people felt that the mask plan was satisfactory (4.2 [SD 0.92] points; 79.5% [n=35] of participants answered “agree” or “strongly agree”). Conclusions We found that the unique name-based mask rationing plan allowed for control of the production and supply of masks, and contributed to the appropriate allocation of masks. The mask rationing plan not only provided the public with physical protection, but also resulted in reduced anxiety about mask shortages during the pandemic.
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Affiliation(s)
- Yu-Lin Tai
- Hsinchu MacKay Memorial Hospital, Department of Pediatrics and Infectious Disease, Hsinchu, Taiwan
| | - Hsin Chi
- MacKay Children's Hospital, Department of Pediatrics and Infectious Disease, Taipei, Taiwan.,MacKay Medical College, Department of Medicine, New Taipei, Taiwan
| | - Nan-Chang Chiu
- MacKay Children's Hospital, Department of Pediatrics and Infectious Disease, Taipei, Taiwan.,MacKay Medical College, Department of Medicine, New Taipei, Taiwan
| | - Cheng-Yin Tseng
- Hsinchu MacKay Memorial Hospital, Department of Pediatrics and Infectious Disease, Hsinchu, Taiwan.,China Medical University, Graduate Institute of Chinese Medicine, School of Chinese Medicine, Taichung, Taiwan
| | - Ya-Ning Huang
- MacKay Children's Hospital, Department of Pediatrics and Infectious Disease, Taipei, Taiwan
| | - Chien-Yu Lin
- Hsinchu MacKay Memorial Hospital, Department of Pediatrics and Infectious Disease, Hsinchu, Taiwan.,MacKay Medical College, Department of Medicine, New Taipei, Taiwan
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Goyal DK, Mansab F, Bhatti S. Room to Breathe: The Impact of Oxygen Rationing on Health Outcomes in SARS-CoV2. Front Med (Lausanne) 2021; 7:573037. [PMID: 33490094 PMCID: PMC7815584 DOI: 10.3389/fmed.2020.573037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
As the primary surge of coronavirus disease 2019 (COVID-19) wanes in many countries, it is important to reconsider best practice. More cases, probably the majority of cases, are yet to come. Hopefully, during this next phase, we will have more time, more resources, and more experience from which to affect better outcomes. Here, we examine the compromised oxygen strategy that many nations followed. We explore the evidence related to such strategies and discuss the potential mortality impact of delaying oxygen treatment in COVID-19 pneumonia.
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Affiliation(s)
- Daniel K. Goyal
- COVID-19 Research Group, Public Health Gibraltar, Gibraltar Health Authority, Gibraltar, United Kingdom
- Department of Medicine, Acute General Medicine, St. Bernard's Hospital, Gibraltar, United Kingdom
- Department of Postgraduate Medicine, University of Gibraltar, Gibraltar, United Kingdom
| | - Fatma Mansab
- COVID-19 Research Group, Public Health Gibraltar, Gibraltar Health Authority, Gibraltar, United Kingdom
- Department of Postgraduate Medicine, University of Gibraltar, Gibraltar, United Kingdom
| | - Sohail Bhatti
- COVID-19 Research Group, Public Health Gibraltar, Gibraltar Health Authority, Gibraltar, United Kingdom
- Department of Postgraduate Medicine, University of Gibraltar, Gibraltar, United Kingdom
- Director of Public Health, Gibraltar Health Authority, Gibraltar, United Kingdom
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Vagner VD, Kireev VV. [Analysis of the application of lean manufacturing tools in the dental service]. Stomatologiia (Mosk) 2021; 100:67-70. [PMID: 34752038 DOI: 10.17116/stomat202110005167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
THE AIM OF THE STUDY Synchronization of methods and tools of lean manufacturing (BP) and the possibility of their practical application in the organization of the dental service. MATERIALS AND METHODS The methods of synthesis and analysis of data from scientific sources and regulatory documents and the empirical method were used to study the use of various BP tools in the management of dental organizations. RESULTS In the course of studying the possibility of using BP tools in the dental service, their systematization was carried out on the basis of the principle of use in dental medical organizations. CONCLUSION The use of BP tools in the management of dental organizations allows them to correspond to a certain extent to the new model of a medical organization.
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Affiliation(s)
- V D Vagner
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
| | - V V Kireev
- Rostov-on-Don Dental Clinic, Rostov-on-Don, Russia
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Abstract
OBJECTIVES To determine the use and expenditure associated with cystic fibrosis (CF) modulator therapies in Ireland since their reimbursement in 2013. DESIGN A retrospective analysis of a national drug claims database. SETTING The data included in this study are nationally representative (Ireland). PARTICIPANTS Data on all persons receiving CF modulator therapies were included. METHODS We obtained national claims data for CF therapies from the Health Service Executive's Primary Care Reimbursement Service. We determined the use and expenditure associated with CF therapies from January 2012 to March 2020. RESULTS The increased prescribing of CF modulator therapies was associated with an approximate fivefold increase in expenditure from €23 million in 2013 to €113 million in 2019. Many patients who initiated lumacaftor/ivacaftor in 2017 went on to receive symptomatic therapies, and subsequently initiated tezacaftor/ivacaftor in 2019. CONCLUSION Despite none of these modulator therapies demonstrating value for money when subjected to health technology assessment, the associated Irish expenditure reached €113 million in 2019 alone.
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Affiliation(s)
- Amelia Smith
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, University of Dublin Trinity College, Dublin, Ireland
- Medicines Management Programme, Health Service Executive, Dublin, Ireland
| | - Michael Barry
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James's Hospital, University of Dublin Trinity College, Dublin, Ireland
- Medicines Management Programme, Health Service Executive, Dublin, Ireland
- National Centre for Pharmacoeconomics, St. James's Hospital, Dublin, Ireland
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Eastwood K, Nambiar D, Dwyer R, Lowthian JA, Cameron P, Smith K. Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study. BMJ Open 2020; 10:e042351. [PMID: 33158837 PMCID: PMC7651717 DOI: 10.1136/bmjopen-2020-042351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches. OBJECTIVES To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch. DESIGN A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted. SETTING The secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period. PARTICIPANTS There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses. MAIN OUTCOME MEASURES Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients. RESULTS The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005). CONCLUSION Secondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
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Affiliation(s)
- Kathryn Eastwood
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Dhanya Nambiar
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rosamond Dwyer
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Judy A Lowthian
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Bolton Clarke Research Institute, Bolton Clarke, Bentleigh, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
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Abstract
The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.
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Affiliation(s)
| | | | - P Anne Scott
- 8799National University of Ireland Galway, Ireland
| | | | - Riitta Suhonen
- 8058University of Turku, Finland; Turku University Hospital, Finland; City of Turku Welfare Division, Finland
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43
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Asgary R, Lawrence K. Evaluating underpinning, complexity and implications of ethical situations in humanitarian operations: qualitative study through the lens of career humanitarian workers. BMJ Open 2020; 10:e039463. [PMID: 32938603 PMCID: PMC7497554 DOI: 10.1136/bmjopen-2020-039463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited. METHODS We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations. RESULTS 61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks. CONCLUSIONS Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.
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Affiliation(s)
- Ramin Asgary
- Global Health, George Washington University Milken Institute of Public Health, Washington, District of Columbia, USA
- Medicine, Weill Cornell Medical College, New York, New York, USA
- Medical Department, Medecins Sans Frontieres/Doctors Without Borders, Paris, France
| | - Katharine Lawrence
- Population Health, New York University School of Medicine, New York, New York, USA
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Konkin J, Grave L, Cockburn E, Couper I, Stewart RA, Campbell D, Walters L. Exploration of rural physicians' lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study. BMJ Open 2020; 10:e037705. [PMID: 32847915 PMCID: PMC7451271 DOI: 10.1136/bmjopen-2020-037705] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services. DESIGN A hermeneutic phenomenological study. SETTING An international rural medicine conference. PARTICIPANTS All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited. INTERVENTIONS Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group. PRIMARY OUTCOME MEASURE An understanding of the lived experiences of clinical courage. RESULTS Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one's own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again. CONCLUSION This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.
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Affiliation(s)
- Jill Konkin
- Office of Rural and Regional Health, University of Alberta, Edmonton, Alberta, Canada
| | - Laura Grave
- Flinders Rural Health South Australia, Flinders University, Mount Gambier, South Australia, Australia
| | - Ella Cockburn
- Flinders Rural Health South Australia, Flinders University, Mount Gambier, South Australia, Australia
| | - Ian Couper
- Ukwanda Centre for Rural Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ruth Alison Stewart
- Rural Medicine, College or Medicine and Dentistry, James Cook University Faculty of Medicine Health and Molecular Sciences, Thursday Island, Queensland, Australia
| | - David Campbell
- Australian College of Rural and Remote Medicine, Lakes Entrance, Victoria, Australia
| | - Lucie Walters
- Adelaide Rural Clinical School, The University of Adelaide Faculty of Health and Medical Sciences, Mount Gambier, South Australia, Australia
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Abstract
Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as "beneficial," "effective," or even "futile," the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient Greek philosophical conundrum known as the "sorites paradox." I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing).
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Affiliation(s)
- Philip M Rosoff
- Duke University School of Medicine, Durham, North Carolina, USA
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46
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Affiliation(s)
- Joel Zivot
- Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, Atlanta, GA
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47
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Khotimchenko SA, Gmoshinski IV, Bagryantseva OV, Shatrov GN. [Chemical food safety: development of methodological and regulatory base]. Vopr Pitan 2020; 89:110-124. [PMID: 32986326 DOI: 10.24411/0042-8833-2020-10047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022]
Abstract
The review presents the results of studies carried out in the Federal Research Centre of Nutrition and Biotechnology in the direction of food toxicology, the purpose of which was to improve the risk assessment methodology, substantiate hygienic regulations for the content of chemical contaminants in foodstuffs and develop methods for their detection and quantitative determination. New challenges and problems associated with the control and regulation of chemical contaminants in foods are associated, firstly, with the identification of previously unrecognized chemical factors harmful to human health, and, secondly, are caused by the progress of technologies, accompanied by the emergence of new sources of nutrients and methods of processing foodstuffs, which, along with many benefits and advantages, creates new potential risks to consumer health. Among the priority chemical pollutants, which should be mentioned currently as objects of improved regulation and control methods, are toxic elements (organic and inorganic forms of arsenic, mercury, nickel), veterinary drugs, phycotoxins, phytotoxins, new mycotoxins, various forms of polychlorinated biphenyls and polycyclic aromatic hydrocarbons, biologically active substances of plant origin, concentrated during the production of extracts, as well as so-called technological contaminants, food additives, residual amounts of technological aids. An independent problem is the assessment of risks from nanoparticles and nanomaterials used in the production of foodstuffs, as well as enzyme preparations and food ingredients produced with the help of genetically modified microorganisms. The system of toxicological and hygienic assessment and control of chemical contaminants in foodstuffs operating in Russia is constantly being improved on the basis of new scientific data to substantiate the permissible levels of their content in products and new methods of analysis. The results obtained are reflected in the regulatory documents of the Russian Federation and the Eurasian Economic Union.
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Affiliation(s)
- S A Khotimchenko
- Federal Research Centre for Nutrition, Biotechnology and Food Safety, 109240, Moscow, Russian Federation.,I.M. Sechenov First Moscow State Medical University of Ministry of Healthcare of the Russian Federation (Sechenov University), 119991, Moscow, Russian Federation
| | - I V Gmoshinski
- Federal Research Centre for Nutrition, Biotechnology and Food Safety, 109240, Moscow, Russian Federation
| | - O V Bagryantseva
- Federal Research Centre for Nutrition, Biotechnology and Food Safety, 109240, Moscow, Russian Federation.,I.M. Sechenov First Moscow State Medical University of Ministry of Healthcare of the Russian Federation (Sechenov University), 119991, Moscow, Russian Federation
| | - G N Shatrov
- Federal Research Centre for Nutrition, Biotechnology and Food Safety, 109240, Moscow, Russian Federation
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Abstract
The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.
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49
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Silberzweig J, Ikizler TA, Kramer H, Palevsky PM, Vassalotti J, Kliger AS. Rationing Scarce Resources: The Potential Impact of COVID-19 on Patients with Chronic Kidney Disease. J Am Soc Nephrol 2020; 31:1926-1928. [PMID: 32669321 DOI: 10.1681/asn.2020050704] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Jeffrey Silberzweig
- The Rogosin Institute, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York
| | - T Alp Ikizler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Holly Kramer
- Departments of Public Health Sciences and Medicine, Division of Nephrology, Loyola University Chicago, Maywood, Illinois
| | - Paul M Palevsky
- Renal Section, Veterans Affairs Pittsburgh Healthcare System University Drive Division, Pittsburgh, Pennsylvania.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph Vassalotti
- Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Alan S Kliger
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, Rosen T, Hwang U, Witt LJ, Thothala N, Liu SW, Vitale CA, Braun UK, Stephens C, Saliba D. AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond. J Am Geriatr Soc 2020; 68:1136-1142. [PMID: 32374440 PMCID: PMC7267615 DOI: 10.1111/jgs.16537] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023]
Abstract
Coronavirus disease 2019 (COVID-19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short-term (not long-term) outcomes; (4) avoiding ancillary criteria such as "life-years saved" and "long-term predicted life expectancy" that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID-19, aligning with AGS positions. The statement also includes recommendations for post-pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136-1142, 2020.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, Utah, USA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Teneille Brown
- Center for Law and the Biomedical Sciences, University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Program in Medical Ethics and Humanities, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Leslie Francis
- University of Utah S.J. Quinney College of Law, Salt Lake City, Utah, USA.,Department of Philosophy, University of Utah, Salt Lake City, Utah, USA
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Ramona Rhodes
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.,Central Arkansas Veterans Healthcare System, Geriatric Research, Education, and Clinical Center, Little Rock, Arkansas, USA
| | - Tony Rosen
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, New York, USA
| | - Ula Hwang
- Department of Emergency Medicine & Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Leah J Witt
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Division of UCSF Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Niranjan Thothala
- Hospitalist Division, Department of Medicine, Good Samaritan Hospital, Vincennes, Indiana, USA.,Hospitalist Division, Department of Medicine, Union Hospital, Terre Haute, Indiana, USA
| | - Shan W Liu
- Department of Emergency Medicine, Division of Geriatric Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Caroline A Vitale
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan, USA
| | - Ursula K Braun
- Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Rehabilitation and Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | | | - Debra Saliba
- UCLA Borun Center for Gerontological Research, Los Angeles, California, USA.,VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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