The Evolution of Inequity in the Access to Health Care in Spain: 1987-2001

This paper reports an analysis of the evolution of income related health inequalities in Spain over the period 1987-2001. We use recently developed methods in order to cardinalise and model self assessed health within a regression framework, decompose the sources of inequality and explain the observed differences between 1987 (one year after the 1986 General Health Act was approved) and 2001 (the latest available representative data on health for the Spanish population). The results show that the period has witnessed a reduction in income related health inequality. The driver of such reduction has been the weakening of the income health gradient, which lends support to the hypothesis that the important health policy reforms implemented over the period have been successful in the objective of reducing socio-economic inequalities in health. Our results also suggest that actions aimed at improving the health of those with low levels of education and of those who are not actively participating in the labor market would lead to further reductions in income related health inequality.

Unobserved heterogeneity and censoring in the demand for health care

This paper analyses the demand for private health care by Spanishhouseholds using a micro budget survey. The methodology used takescare of the three part decision process involved in this type ofbehaviour, namely the decision to use private health care, howoften to do so and how much to spend each time and also the effectsof unobserved heterogeneity. Since the theoretical frameworkcorresponds to the Grossman model of health investment, the resultsalso provide a test of the theory when these issues are considered.Finally, the obtained evidence also suggest that the current systemof tax deductions for private health care expenditures is regressive.

Public Health and Health Care Task Force Report, August 2008

The Rebuild Iowa Public Health and Health Care Task Force respectfully submits its report to the Rebuild Iowa Advisory Commission (RIAC) for its consideration of the impacts of the tornadoes, storms, and flooding on Iowans. As the RIAC fulfills its obligations to guide the recovery and reconstruction in Iowa, the impact on the health and well-being of Iowans should be of primary concern. With many areas of the state experiencing devastating damage to their communities, public health and health care are but one of the major challenges. There are critical immediate needs to address the health, safety, and well-being of affected Iowans. This report provides background information on the damages incurred in Iowa from the disasters and additional context for policy and rebuilding discussions. It also offers recommendations to the RIAC for steps that might be taken to address these significant and important challenges.

The influence of drugs used in cardiac anaesthesia and critical care on multiple electrode aggregometry: an in-vitro volunteer study.

BACKGROUND: Multiple electrode aggregometry (MEA) is a point-of-care test evaluating platelet function and the efficacy of platelet inhibitors. In MEA, electrical impedance of whole blood is measured after addition of a platelet activator. Reduced impedance implies platelet dysfunction or the presence of platelet inhibitors. MEA plays an increasingly important role in the management of perioperative platelet dysfunction. In vitro, midazolam, propofol, lidocaine and magnesium have known antiplatelet effects and these may interfere with MEA interpretation. OBJECTIVE: To evaluate the extent to which MEA is modified in the presence of these drugs. DESIGN: An in-vitro study using blood collected from healthy volunteers. SETTING: Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, 2010 to 2011. PATIENTS: Twenty healthy volunteers. INTERVENTION: Measurement of baseline MEA was using four activators: arachidonic acid, ADP, TRAP-6 and collagen. The study drugs were then added in three increasing, clinically relevant concentrations. MAIN OUTCOME MEASURE: MEA was compared with baseline for each study drug. RESULTS: Midazolam, propofol and lidocaine showed no effect on MEA at any concentration. Magnesium at 2.5 mmol l had a significant effect on the ADP and TRAP tests (31 ± 13 and 96 ± 39 AU, versus 73 ± 21 and 133 ± 28 AU at baseline, respectively), and a less pronounced effect at 1 mmol l on the ADP test (39 ± 0 AU). CONCLUSION: Midazolam, propofol and lidocaine do not interfere with MEA measurement. In patients treated with high to normal doses of magnesium, MEA results for ADP and TRAP-tests should be interpreted with caution. TRIAL REGISTRATION: Clinicaltrials.gov (no. NCT01454427).

Supplemental Information to the August 2008 Public Health and Health Care Task Force Report, August 2008

The Rebuild Iowa Public Health and Health Care Task Force respectfully submits its report to the Rebuild Iowa Advisory Commission (RIAC) for its consideration of the impacts of the tornadoes, storms, and flooding on Iowans. As the RIAC fulfills its obligations to guide the recovery and reconstruction in Iowa, the impact on the health and well-being of Iowans should be of primary concern. With many areas of the state experiencing devastating damage to their communities, public health and health care are but one of the major challenges. There are critical immediate needs to address the health, safety, and well-being of affected Iowans. This report provides background information on the damages incurred in Iowa from the disasters and additional context for policy and rebuilding discussions. It also offers recommendations to the RIAC for steps that might be taken to address these significant and important challenges.

Treatment patterns and health care resource utilization in a 1-year observational cohort study of outpatients with schizophrenia at risk of nonadherence treated with long-acting injectable antipsychotics

Purpose: To describe (1) the clinical profiles and the patterns of use of long-acting injectable (LAI) antipsychotics in patients with schizophrenia at risk of nonadherence with oral antipsychotics, and in those who started treatment with LAI antipsychotics, (2) health care resource utilization and associated costs. Patients and methods: A total of 597 outpatients with schizophrenia at risk of nonadherence, according to the psychiatrist's clinical judgment, were recruited at 59 centers in a noninterventional prospective observational study of 1-year follow-up when their treatment was modified. In a post hoc analysis, the profiles of patients starting LAI or continuing with oral antipsychotics were described, and descriptive analyses of treatments, health resource utilization, and direct costs were performed in those who started an LAI antipsychotic. Results: Therapy modifications involved the antipsychotic medications in 84.8% of patients, mostly because of insufficient efficacy of prior regimen. Ninety-two (15.4%) patients started an LAI antipsychotic at recruitment. Of these, only 13 (14.1%) were prescribed with first-generation antipsychotics. During 1 year, 16.3% of patients who started and 14.9% of patients who did not start an LAI antipsychotic at recruitment relapsed, contrasting with the 20.9% who had been hospitalized only within the prior 6 months. After 1 year, 74.3% of patients who started an LAI antipsychotic continued concomitant treatment with oral antipsychotics. The mean (median) total direct health care cost per patient per month during the study year among the patients starting any LAI antipsychotic at baseline was 1,407 ( 897.7). Medication costs (including oral and LAI antipsychotics and concomitant medication) represented almost 44%, whereas nonmedication costs accounted for more than 55% of the mean total direct health care costs. Conclusion: LAI antipsychotics were infrequently prescribed in spite of a psychiatrist-perceived risk of nonadherence to oral antipsychotics. Mean medication costs were lower than nonmedication costs.

The development and pilot-testing of a training curriculum in adolescent medicine and health.

PURPOSE: To select and propose a set of knowledge, attitudes, and skills essential for the care of adolescents; to encourage the development of adolescent health multidisciplinary networks; and to set up training programs in as many European countries as possible. METHODS: The curriculum was developed by 16 physicians from 11 European countries with various professional specializations. In line with modern guidelines in medical education, it is a modular, flexible instrument which covers the main teaching areas in the field, such as basic skills (i.e. setting, rights and confidentiality, gender and cultural issues) as well as specific themes (i.e. sexual and reproductive health, eating disorders, chronic conditions). It consists of 17 thematic modules, each containing detailed objectives, learning approaches, examples, and evaluation methods. RESULT: Two international one-week summer schools were used to assess the feasibility and appropriateness of the curriculum. The overall evaluation was good, with most of the items surpassing three on a four-point Likert scale. However, it pointed to several aspects (process and content) which will need to be refined in the future, such as an increase in interactive sessions (role playing), and a better mix of clinical and public health issues.

Treatment patterns and health care resource utilization in a 1-year observational cohort study of outpatients with schizophrenia at risk of nonadherence treated with long-acting injectable antipsychotics

Purpose: To describe (1) the clinical profiles and the patterns of use of long-acting injectable (LAI) antipsychotics in patients with schizophrenia at risk of nonadherence with oral antipsychotics, and in those who started treatment with LAI antipsychotics, (2) health care resource utilization and associated costs. Patients and methods: A total of 597 outpatients with schizophrenia at risk of nonadherence, according to the psychiatrist's clinical judgment, were recruited at 59 centers in a noninterventional prospective observational study of 1-year follow-up when their treatment was modified. In a post hoc analysis, the profiles of patients starting LAI or continuing with oral antipsychotics were described, and descriptive analyses of treatments, health resource utilization, and direct costs were performed in those who started an LAI antipsychotic. Results: Therapy modifications involved the antipsychotic medications in 84.8% of patients, mostly because of insufficient efficacy of prior regimen. Ninety-two (15.4%) patients started an LAI antipsychotic at recruitment. Of these, only 13 (14.1%) were prescribed with first-generation antipsychotics. During 1 year, 16.3% of patients who started and 14.9% of patients who did not start an LAI antipsychotic at recruitment relapsed, contrasting with the 20.9% who had been hospitalized only within the prior 6 months. After 1 year, 74.3% of patients who started an LAI antipsychotic continued concomitant treatment with oral antipsychotics. The mean (median) total direct health care cost per patient per month during the study year among the patients starting any LAI antipsychotic at baseline was 1,407 ( 897.7). Medication costs (including oral and LAI antipsychotics and concomitant medication) represented almost 44%, whereas nonmedication costs accounted for more than 55% of the mean total direct health care costs. Conclusion: LAI antipsychotics were infrequently prescribed in spite of a psychiatrist-perceived risk of nonadherence to oral antipsychotics. Mean medication costs were lower than nonmedication costs.

JOHTAMISOPIT KUNTAORGANISAATIOSSA – diskursiivinen tutkimus sosiaali- ja terveystoimesta 1980-luvulta 2000-luvulle

Julkisen sektorin johtamista on uudistettu viime vuosikymmeninä uuden julkisjohtamisen suuntauksen kautta. Tässä keskeistä ovat olleet markkinamekanismin sekä yksityissektorin johtamisoppien soveltaminen julkiselle sektorille. Tämän tutkimuksen tarkoituksena on tuottaa tietoa johtamisoppien soveltamisesta kuntaorganisaation sosiaalija terveystoimessa. Mielenkiinnon kohteena ovat kysymykset, miten johtamisopit ovat tulleet kuntaorganisaatioon ja miten ne ovat levinneet, rakentuneet sekä rakentaneet kontekstiaan tarkasteluajanjaksolla 1985 - 2007. Tutkimuksen lähestymistapa on diskurssianalyyttinen ja nojaa epistemologialtaan tulkinnallisesta tieteen filosofiasta nousseeseen sosiaaliseen konstruktivismiin. Oppien leviämistä tarkastellaan tässä tutkimuksessa translaationa, kääntämisprosessina, jossa opin johtoportaaseen tullut ensimmäinen versio tulkitaan ja käännetään organisaation kielelle ja käytännöiksi. Oppien rakentumista kontekstissaan käsitteellistetään sedimentoitumisen käsitteen kautta, mikä auttaa ymmärtämään uusien ja vanhojen oppien elementtien kerrostumista lähes muuttumattomista syvärakenteista nopeasti muuttuviin pintarakenteisiin. Tutkimuksen kohdeorganisaationa on suomalainen, keskikokoinen kuntaorganisaatio. Aineistona on käytetty kirjallisia dokumentteja ja haastatteluja. Johtamisoppeja kuntaorganisaatioon välittäviä tahoja ovat olleet konsulttiyritykset, yliopistot, kuntien johtoportaan verkostot, uudet johtajat sekä koulutuspäivät. Organisaation valmius uuden johtamisopin omaksumiseen on yhteydessä organisaatioon, johtoon, tarjolla oleviin oppeihin sekä toimintaympäristöön liittyviin tekijöihin Levitäkseen organisaatiossa oppi tarvitsee johdon tasolta kannattajan, joka markkinoi sitä muulle virkamies- ja luottamushenkilöjohdolle. Kun oppi saavuttaa johdon enemmistön tuen, käynnistyy sen kääntämisprosessi johdon puheesta henkilöstön puheen ja käytäntöjen tasolle. Uudet johtamisopit kyseenalaistavat vanhoja ”totuuksia” ja samalla ne määrittävät, mikä on tärkeää ja mikä jää huomiotta. Uudet opit eivät syrjäytä kokonaan vanhoja, vaan opit sedimentoituvat: vanhojen oppien diskursiivisia elementtejä jää pois ja uusien oppien elementtejä tulee mukaan johtamispuheeseen. Johtamisopit rakentavat kontekstiaan sekä puheen, käytäntöjen että organisaatiorakenteiden tasolla, mutta joihinkin syvärakenteisiin ne eivät ole pystyneet vaikuttamaan tai vaikuttavat äärimmäisen hitaasti. Asiakaslähtöisyys muun muassa on ollut useimpien johtamisoppien diskursiivinen elementti, mutta se on jäänyt toistuvasti kuntaorganisaation sosiaali- ja terveystoimessa organisaatiolähtöisen palvelujen järjestämistavan ja talouden kautta tapahtuvan tuloksellisuuden arvioinnin varjoon. Diskurssit muutoksesta ja sen välttämättömyydestä, tehokkuudesta sekä julkisen rinnastaminen yksityiseen näyttäytyivät tässä tutkimuksessa metatason diskursseina, jotka oikeuttavat yksityiseltä sektorilta lähtöisin olevien johtamisdiskurssien soveltamisen muutoksen ja tehokkuuden aikaansaamiseksi julkiselle sektorille. Kuntien sosiaali- ja terveystoimen tuloksellisuuden ja tehokkuuden arviointi on kapeutunut liikkeenjohdon peruslähtökohdista nousevaksi talouden kautta tapahtuvaksi arvioinniksi. Tässä julkisen toiminnan omiin arvolähtökohtiin ja teoriataustaan pohjautuvien toiminnan tulosten ja saavutettujen hyvinvointivaikutusten arviointi sekä näistä kertovien mittarien kehittäminen yhdessä talouden mittarien kanssa on marginaaliin jäänyttä, mutta nousevaa puhetta.

Variance in Bioethics Services: Challenges and Opportunities in Canada with a Focus on In-house vs. Outsourced Health Care Ethics Consultations

Étude de cas / Case study

Unravelling the conundrum of tannins in animal nutrition and health

This paper examines the nutritional and veterinary effects of tannins on ruminants and makes some comparisons with non-ruminants. Tannin chemistry per se is not covered and readers are referred to several excellent reviews instead: (a) Okuda T et al. Heterocycles 30:1195-1218 (1990); (b) Ferreira D and Slade D. Nat Prod Rep 19:517-541 (2002); (c) Yoshida T et al. In Studies in Natural Product Chemistry. Elsevier Science, Amsterdam, pp. 395-453 (2000); (d) Khanbabaee K and van Ree T. Nat Prod Rep 18:641-649 (2001); (e) Okuda et al. Phytochemistvy 55:513-529 (2000). The effects of tannins on rumen micro-organisms are also not reviewed, as these have been addressed by others: (a) McSweeney CS et al. Anim Feed Sci Technol 91:83-93 (2001); (b) Smith AH and Mackie RI. Appl Environ Microbiol 70:1104-1115 (2004). This paper deals first with the nutritional effects of tannins in animal feeds, their qualitative and quantitative diversity, and the implications of tannin-protein complexation. It then summarises the known physiological and harmful effects and discusses the equivocal evidence of the bioavailability of tannins. Issues concerning tannin metabolism and systemic effects are also considered. Opportunities are presented on how to treat feeds with high tannin contents, and some lesser-known but successful feeding strategies are highlighted. Recent research has explored the use of tannins for preventing animal deaths from bloat, for reducing intestinal parasites and for lowering gaseous ammonia and methane emissions. Finally, several tannin assays and a hypothesis are discussed that merit further investigation in order to assess their suitability for predicting animal responses. The aim is to provoke discussion and spur readers into new approaches. An attempt is made to synthesise the emerging information for relating tannin structures with their activities. Although many plants with high levels of tannins produce negative effects and require treatments, others are very useful animal feeds. Our ability to predict whether tannin-containing feeds confer positive or negative effects will depend on interdisciplinary research between animal nutritionists and plant chemists. The elucidation of tannin structure-activity relationships presents exciting opportunities for future feeding strategies that will benefit ruminants and the environment within the contexts of extensive, semi-intensive and some intensive agricultural systems. (c) 2006 Society of Chemical Industry

Unravelling the conundrum of tannins in animal nutrition and health

This paper examines the nutritional and veterinary effects of tannins on ruminants and makes some comparisons with non-ruminants. Tannin chemistry per se is not covered and readers are referred to several excellent reviews instead: (a) Okuda T et al. Heterocycles 30:1195-1218 (1990); (b) Ferreira D and Slade D. Nat Prod Rep 19:517-541 (2002); (c) Yoshida T et al. In Studies in Natural Product Chemistry. Elsevier Science, Amsterdam, pp. 395-453 (2000); (d) Khanbabaee K and van Ree T. Nat Prod Rep 18:641-649 (2001); (e) Okuda et al. Phytochemistvy 55:513-529 (2000). The effects of tannins on rumen micro-organisms are also not reviewed, as these have been addressed by others: (a) McSweeney CS et al. Anim Feed Sci Technol 91:83-93 (2001); (b) Smith AH and Mackie RI. Appl Environ Microbiol 70:1104-1115 (2004). This paper deals first with the nutritional effects of tannins in animal feeds, their qualitative and quantitative diversity, and the implications of tannin-protein complexation. It then summarises the known physiological and harmful effects and discusses the equivocal evidence of the bioavailability of tannins. Issues concerning tannin metabolism and systemic effects are also considered. Opportunities are presented on how to treat feeds with high tannin contents, and some lesser-known but successful feeding strategies are highlighted. Recent research has explored the use of tannins for preventing animal deaths from bloat, for reducing intestinal parasites and for lowering gaseous ammonia and methane emissions. Finally, several tannin assays and a hypothesis are discussed that merit further investigation in order to assess their suitability for predicting animal responses. The aim is to provoke discussion and spur readers into new approaches. An attempt is made to synthesise the emerging information for relating tannin structures with their activities. Although many plants with high levels of tannins produce negative effects and require treatments, others are very useful animal feeds. Our ability to predict whether tannin-containing feeds confer positive or negative effects will depend on interdisciplinary research between animal nutritionists and plant chemists. The elucidation of tannin structure-activity relationships presents exciting opportunities for future feeding strategies that will benefit ruminants and the environment within the contexts of extensive, semi-intensive and some intensive agricultural systems. (c) 2006 Society of Chemical Industry