There are several ethical concerns facing first‐in‐human clinical trials involving xenotransplantation. Who should participate in these trials? If we limit trial participation to those who have ...exhausted other treatment options, how can we avoid therapeutic misconception? How should we balance the desire for long‐term monitoring of trial participants against the well‐established principle that research participants have the right to withdraw from research? Finally, how should we balance concerns about equitable access to these trials with deep mistrust of the scientific community? In particular, should xenotransplant clinical trials attempt to address well‐known inequities in clinical trial participation by race and ethnicity? In this commentary, I argue that clinical investigators and regulators have an obligation to engage with underrepresented communities to develop answers to these questions.
Listening to Scientists—and Each Other Gusmano, Michael K.
The Hastings Center report,
November/December 2020, 2020-11-00, 20201101, Letnik:
50, Številka:
6
Journal Article
Recenzirano
During the past two years, colleagues and I at The Hastings Center have worked on a project, funded by the John S. and James L. Knight Foundation, that seeks to improve the quality of public ...deliberation, particularly about science. Specifically, we seek to improve the public's capacity for civic learning, which is our term for the ability of people living in a democracy to learn at least the basics of complex policy issues, discuss them, and make civically responsible decisions about them. There are no quick fixes. The forces that have undermined trust in society and that inhibit a mutually respectful deliberation about these issues have built up over centuries.
There is strong evidence that housing conditions affect population health, but evidence is limited on the extent to which housing with supportive social services can maintain population health and ...reduce the use of expensive hospital services. We examined a nonprofit, community-based program in Queens, New York, that supplied affordable housing with supportive social services to elderly Medicare beneficiaries. We evaluated whether this program reduced hospital use, including hospital discharges for ambulatory care-sensitive conditions (ACSCs). We compared hospital use among an intervention group residing in six high-rise buildings in two neighborhoods to that among their Medicare counterparts living in the same neighborhoods but in different buildings. We found that hospital discharge rates were 32 percent lower, hospital lengths-of-stay one day shorter, and ACSC rates 30 percent lower among residents in the intervention group than among people in the comparison group. This suggests that investments in housing with supportive social services have the potential to reduce hospital use and thereby decrease spending for vulnerable older patients.
ObjectiveSignificant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate ...avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence.DesignRetrospective observational study.SettingPublic and accredited private hospitals in the metropolitan area of Milan. Data obtained from the hospital discharge database of the Italian Health Ministry.Participants472 579 patients hospitalised for ambulatory care sensitive conditions and resident in the metropolitan area of Milan from 2005 to 2016.Outcome measureAge-adjusted rates of avoidable hospitalisations; OR for hospital admissions with ambulatory care sensitive conditions.MethodsAge-adjusted rates of avoidable hospitalisations in the metropolitan area of Milan were estimated from 2005 to 2016 using direct standardisation. For the hospitalised population, multilevel logistic regression model with patient random effects was used to identify patients, hospitals and municipalities’ characteristics associated with risk of avoidable hospitalisation in the period 2012–2016.ResultsThe rate of avoidable hospitalisation in Milan fell steadily between 2005 and 2016 from 16.6 to 10.5 per 1000. Among the hospitalised population, the odds of being hospitalised with an ambulatory care sensitive condition was higher for male (OR 1.42, 95% CI 1.36 to 1.48), older (OR 1.012, 95% CI 1.01 to 1.014), low-educated (elementary school vs degree OR 4.23, 95% CI 3.72 to 4.81) and single (vs married OR 2.08, 95% CI 2.01 to 2.16) patients with comorbidities (OR 1.47, 95% CI 1.38 to 1.56); avoidable admissions were more frequent in public non-teaching hospitals while municipality’s characteristics did not appear to be correlated with hospitalisation for ambulatory care sensitive conditions.ConclusionsThe health system in metropolitan Milan has experienced a reduction in avoidable hospitalisations between 2005 and 2016, quite homogeneously across its 134 municipalities. The study design allowed to explore inequalities among the hospitalised population for which we found specific sociodemographic disadvantages.
Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor ...strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.
Physician Advocacy for Public Health Gusmano, Michael K.
Journal of health politics, policy and law,
2/2019, Letnik:
44, Številka:
1
Journal Article
Recenzirano
This article documents the public positions taken by the American Academy of Pediatrics, the American College of Physicians, and the American Medical Association on five topics with implications for ...public health: access to care for undocumented patients, fracking, gun control, climate change, and same-sex marriage. There are stark divisions on each of these issues between political parties, and taking a strong public position on them runs the risk of alienating some members of Congress, but each of these associations has done so. At the same time, there is a clear distinction between the public positions of these organizations and the priority given to them by their offices in Washington, DC. Drawing on an organizational maintenance framework, the author argues that taking these public positions is explained, in part, by a growth in the number of women and the number of physicians that affiliate with the Democratic Party in the United States.
Background:
Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use ...of palliative care.
Aim:
Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France.
Design:
Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database
Results:
55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84–2.43) and aOR = 2.59 (2.12–3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels.
Conclusion:
The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.
When the COVID-19 pandemic landed in the United States, and particularly once cases began to grow substantially in March, the entire health care system suffered, but the safety net was exceptionally ...hard hit. The "health care safety net," an ill-defined term that encompasses public and some non-profit hospitals that take care of the poor and uninsured, was on the front lines of taking care of the bulk of individuals who had contracted COVID-19. These hospitals tended to suffer from a lack of adequate supplies and relatively low reimbursement in a system that was already financially weak.
Abstract Objectives The objective of this paper is to assess historical and recent health reform efforts in China. We provide a brief history of the Chinese healthcare system since 1949 as context ...for the current healthcare; examine the factors that led to recent efforts to reestablish community-based care in China; and identify the challenges associated with attaining a sustainable and quality community healthcare system. Methods Based on literature review and publicly available data in China, the paper will present a historical case study analysis of health policy change of CHOs in China and provide policy evaluation, and the paper provided policy suggestions. Results We find that the government's recent efforts to emphasize the significance of community healthcare services in China have started to change patterns of healthcare use, but many problems still inhibit the development of CHOs, including unsustainable governmental roles, issues of human resource inadequacy and laggard GP practice, poorly designed payment schemes, patient's trust crisis and continue to inhibit the development of community-based primary care. Conclusions Additional policy efforts to help CHOs’ development are needed. Recent government investments in public health and primary care alone are not sufficient and could not be sustainable. It will not until long-term self-sustaining mechanisms to relieve an omnipotent government are established, including competent community doctors (GP) system, supportive social insurance reimbursement, appropriate financial incentives to providers, better transparency and accountability, as well as a more regulated referral system, a legitimate, sustainable and quality community health system could be attained.
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