Background What role do people want to play in treatment decision‐making (DM)?
Objective Examine the role patients indicate they would prefer in making treatment decisions across multiple clinical ...settings in Ontario, Canada.
Design Secondary analysis of a series of survey/interview‐based studies measuring preferred role, conducted in 12 different populations.
Setting and participants Respondents were outpatients, largely but not entirely attending outpatient clinics in large teaching hospitals in urban settings in the Province of Ontario, Canada. The subgroups and sample sizes were: breast cancer (202), prostate disease (202), fractures (202), continence (46), orthopaedic (111), rheumatology (56), multiple sclerosis (22), HIV/AIDS (431), infertility (454), benign prostatic hyperplasia (678) and cardiac disease (300), plus 50 healthy nursing students (for scale validation).
Measurements All studies categorized preferred role using the Problem‐Solving Decision‐Making (PSDM) scale with one or both of the Current Health condition and Chest Pain vignettes.
Results Few respondents preferred an autonomous role (1.2% for the current health condition vignette and 0.7% for the chest pain vignette); most preferred shared DM (77.8% current health condition; 65.1% chest pain) or a passive role (20.3% current health condition; 34.1% chest pain). Familiarity with a clinical condition increases desire for a shared (as opposed to passive) role. Preferences for passive vs. shared roles varied across settings; older and less educated individuals were most likely to prefer passive roles.
Conclusions Despite consumerist rhetoric among some bioethicists, very few respondents wish an autonomous role. Most wish to share DM with their providers.
Background:
Why do many patients not die at their preferred location?
Aim:
Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ...ill adults (barriers and facilitators).
Design:
Cross-country comparison study from a “most similar—most different” perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews.
Setting:
Case study of Canada, England, Germany, and the United States.
Results:
While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception (“giving up hope”) challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators.
Conclusion:
Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.
Objective Does trust in physicians aid or hinder patient autonomy? We examine the relationship between trust in the recipient's doctor, and desire for a participative role in decisions about medical ...treatment.
Design We conducted a cross‐sectional survey in an urban Canadian teaching hospital.
Setting and participants A total of 606 respondents in three clinics (breast cancer, prostate cancer, fracture) completed questionnaires.
Variables studied The instrument included the Problem Solving Decision Making (PSDM) Scale, which used two vignettes (current health condition, chest pain) to categorize respondents by preferred role, and the Trust‐in‐Physician Scale.
Results Few respondents preferred an autonomous role (2.9% for the current health condition vignette and 1.2% for the chest pain vignette); most preferred shared decision‐making (DM) (67.3% current health condition; 48.7% chest pain) or a passive role (29.6% current health condition; 50.1% chest pain). Trust‐in‐physician yielded 6.3% with blind trust, 36.1% with high trust, 48.6% moderate trust and 9.0% low trust. As hypothesized, autonomous patients had relatively low levels of trust, passive respondents were more likely to have blind trust, while shared respondents had high but not excessive trust. Trust had a significant influence on preferred role even after controlling for the demographic factors such as sex, age and education.
Conclusions Very few respondents wish an autonomous role; those who do tend to have lower trust in their providers. Familiarity with a clinical condition increases desire for a shared (as opposed to passive) role. Shared DM often accompanies, and may require, a trusting patient–physician relationship.
Policy-makers desire an optimal balance of financial incentives to improve productivity and encourage improved quality in primary care, while also avoiding issues of risk-selection inherent to ...capitation-based payment. In this paper we analyze risk-selection in capitation-based payment by using administrative data for patients (n = 11,600,911) who were rostered (i.e., signed an enrollment form, or received a majority of care) with a primary care physician (n = 8621) in Ontario, Canada in 2010/11. We analyze this data using a relative distribution approach and compare distributions of patient costs and morbidity across primary care payment models. Our results suggest a relationship between being in a capitation-based payment scheme and having low cost patients (and presumably healthy patients) compared to fee-for-service physicians. However, we do not have evidence that physicians in capitation-based models are reducing the care they provide to sick and high cost patients. These findings suggest there is a relationship between payment type and risk-selection, particularly for low-cost and healthy patients.
Accountability is a key component of healthcare reforms, in Canada and internationally, but there is increasing recognition that one size does not fit all. A more nuanced understanding begins with ...clarifying what is meant by accountability, including specifying for what, by whom, to whom and how.
To determine the financial and family resources burden associated with the treatment of cancer. A questionnaire was developed to determine the direct monthly "out-of-pocket costs" (OOPC), the ...indirect costs, and the associated perceived family burden.
A self-administered questionnaire using a quota sample from five cancer clinics in Ontario, Canada was given to 282 cancer patients (74 breast, 70 colorectal, 68 lung, and 70 prostate). Monthly OOPC were obtained for: drugs, home care, homemaking, complementary and alternative medicines, vitamins and supplements, family care, travel, parking, accommodations, devices, and others. The questionnaire asked if OOPC for treatment were a burden, and if others took time from work to provide caregiving.
The mean monthly OOPC was $213, with an additional $372 related to imputed travel costs. For those patients who responded that the burden was "significant" (16.5%), their OOPC was $452. In the case of patients responding that their burden was "unmanageable" (3.9%), their OOPC was $544. The survey showed that 35.6% of patients required others to take time from work and this was higher in the under-65 category. The mean number of days lost from work in the previous 30 days for these caregivers was 7 days.
These results suggest the financial burden is problematic for 20% of this sample. The caregivers' lost time from work influence this burden, and for 36% of this sample, it amounts to one third of their working days in any given month. Policies and programs to address these gaps are needed.
Background:
Increasing emphasis is being placed on the economics of health care service delivery – including home-based palliative care.
Aim:
This paper analyzes resource utilization and costs of a ...shared-care demonstration project in rural Ontario (Canada) from the public health care system’s perspective.
Design:
To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care. Resource utilization and costs were tracked over the 15 month study period from January 2005 to March 2006.
Results:
Of the 95 study participants (average age 71 years), 83 had a cancer diagnosis (87%); the non-cancer diagnoses (12 patients, 13%) included mainly advanced heart diseases and COPD. Community Care Access Centre and Enhanced Palliative Care Team-based homemaking and specialized nursing services were the most frequented offerings, followed by equipment/transportation services and palliative care consults for pain and symptom management. Total costs for all patient-related services (in 2007 $CAN) were $1,625,658.07 – or $17,112.19 per patient/$117.95 per patient day.
Conclusion:
While higher than expenditures previously reported for a cancer-only population in an urban Ontario setting, the costs were still within the parameters of the US Medicare Hospice Benefits, on a par with the per diem funding assigned for long-term care homes and lower than both average alternate level of care and hospital costs within the Province of Ontario. The study results may assist service planners in the appropriate allocation of resources and service packaging to meet the complex needs of palliative care populations.
The findings suggest that accountability is increasingly seen as important. This scrutiny has both positive and negative implications. It forces providers to be aware of what they are doing, and to ...strive to improve their performance. Many of our respondents told us that there is an increased focus on quality. Accountability has moved beyond its traditional focus on financial dimensions (and ensuring that resources are not misappropriated) to add a major focus on performance. These are all positive outcomes.
Almost home Baranek, Patricia M; Deber, Raisa B; Williams, A. Paul
Almost home,
c2004, 20040930, 2004, 2014, 2004-01-01, 20040101
eBook
Almost Homeis a rich and comprehensive study of the policy questions underlying the shift in medical care from hospitals to homes and communities, a change that is reshaping Canadian health care ...policy and politics. Using document analysis, and interviews with government officials and other key stakeholders in the policy community, the authors analyze the policy content and process of five different attempts to reform home and community care in Ontario between 1985 and 1996, as introduced by governments from three different political parties.
As this study demonstrates, the ongoing shift from the Medicare 'mainstream' of physician and hospital care to the Medicare 'margins,' entails not only a shift in the site of care but an erosion of the post-war state's role in health care. While Medicare continues to resist political and ideological forces aimed at shrinking the state's role, cost constraints, demographic pressures and technological advancements are increasing pressure on home and community care.
The authors have made a significant contribution to research on policy development and change. Their rigorously analytical approach fills a major gap in book-length literature on long-term health care in Canada.
Policy debates about immunization frequently focus on classic trade-offs between individual versus collective well-being. Publicly funded immunization programs are usually justified on the basis of ...widespread public benefit with minimal individual risk. We discuss the example of the policy process surrounding the adoption of the human papillomavirus (HPV) vaccine in Canada to consider whether public good arguments continue to dominate immunization policymaking. Specifically, we show how a range of stakeholders framed HPV vaccination as a personal-rather than a public-matter, despite the absence of a controversy over mandatory immunization as was the case in the United States. Our findings suggest an erosion of the persuasiveness of public good arguments around collective immunization programs in the policy discourse.
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