Perspectives of Canadian health leaders on the relationship between medical assistance in dying and palliative and end-of-life care services: a qualitative study.

BACKGROUND: Medical assistance in dying (MAiD) was legalized in Canada in 2016, but coordination of MAiD and palliative and end-of-life care (PEOLC) services remains underdeveloped. We sought to understand the perspectives of health leaders across Canada on the relationship between MAiD and PEOLC services and to identify opportunities for improved coordination. METHODS: In this quantitative study, we purposively sampled health leaders across Canada with expertise in MAiD, PEOLC, or both. We conducted semi-structured interviews between April 2021 and January 2022. Interview transcripts were coded independently by 2 researchers and reconciled to identify key themes using content analysis. We applied the PATH framework for Integrated Health Services to guide data collection and analysis. RESULTS: We conducted 36 interviews. Participants expressed diverse views about the optimal relationship between MAiD and PEOLC, and the desirability of integration, separation, or coordination of these services. We identified 11 themes to improve the relationship between the services across 4 PATH levels: client-centred services (e.g., educate public); health operations (e.g., cultivate compassionate and proactive leadership); health systems (e.g., conduct broad and inclusive consultation and planning); and intersectoral initiatives (e.g., provide standard practice guidelines across health care systems). INTERPRETATION: Health leaders recognized that cooperation between MAiD and PEOLC services is required for appropriate referrals, care coordination, and patient care. They identified the need for public and provider education, standardized practice guidelines, relationship-building, and leadership. Our findings have implications for MAiD and PEOLC policy development and clinical practice in Canada and other jurisdictions.

Dialysis costs for a health system participating in value-based care.

OBJECTIVES: Unplanned "crash" dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). We examined expenditures and utilization associated with these events in a large health system. STUDY DESIGN: Retrospective, single-center study at Cleveland Clinic, a large, integrated health system participating in VBC contracts, including a Medicare accountable care organization. METHODS: We analyzed beneficiaries who transitioned to dialysis between 2017 and 2020. Crash starts involved initiating inpatient hemodialysis (HD) with a central venous catheter (CVC). Optimal starts were initiated with either home dialysis or outpatient HD without a CVC. Suboptimal starts were initiated with outpatient HD with a CVC or inpatient HD without a CVC. RESULTS: A total of 495 patients initiated chronic dialysis: 260 crash starts, 130 optimal starts, and 105 suboptimal starts. Median predialysis 12-month cost was $67,059 for crash starts, $17,891 for optimal starts, and $7633 for suboptimal starts (P < .001). Median postdialysis 12-month cost was $71,992 for crash starts, $55,427 for optimal starts, and $72,032 for suboptimal starts (P = .001). Predialysis inpatient admission per 1000 beneficiaries was 1236 per 1000 for crash starts vs 273 per 1000 for optimal starts and 170 per 1000 for suboptimal starts (P < .001). Postdialysis inpatient admission for crash starts was 853 per 1000 vs 291 per 1000 for optimal starts and 184 per 1000 for suboptimal starts (P < .001). CONCLUSIONS: In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance.

eHealth or e-Chaos: The use of Digital Health Interventions for Health Systems Strengthening in sub-Saharan Africa over the last 10 years: A scoping review.

Background: Digital health solutions are a potent and complementary intervention in health system strengthening to accelerate universal access to health services. Implementing scalable, sustainable, and integrated digital solutions in a coordinated manner is necessary to experience the benefits of digital interventions in health systems. We sought to establish the breadth and scope of available digital health interventions (DHIs) and their functions in sub-Saharan Africa. Methods: We conducted a scoping review according to the Joanne Briggs Institute's reviewers manual and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist and explanation. We retrieved data from the WHO Digital Health Atlas (DHA), the WHO e-Health country profiles report of 2015, and electronic databases. The protocol has been deposited in an open-source platform - the Open Science Framework at https://osf.io/5kzq7. Results: The researchers retrieved 983 digital tools used to strengthen health systems in sub-Saharan Africa over the past 10 years. We included 738 DHIs in the analysis while 245 were excluded for not meeting the inclusion criteria. We observed a disproportionate distribution of DHIs towards service delivery (81.7%, n = 603), health care providers (91.8%, n = 678), and access and use of information (84.1%, n = 621). Fifty-three percent (53.4%, n = 394) of the solutions are established and 47.5% (n = 582) were aligned to 20% (n = 5) of the system categories. Conclusions: Sub-Saharan Africa is endowed with digital health solutions in both numbers and distinct functions. It is lacking in coordination, integration, scalability, sustainability, and equitable distribution of investments in digital health. Digital health policymakers in sub-Saharan Africa need to urgently institute coordination mechanisms to terminate unending duplication and disjointed vertical implementations and manage solutions for scale. Central to this would be to build digital health leadership in countries within SSA, adopt standards and interoperability frameworks; advocate for more investments into lagging components, and promote multi-purpose solutions to halt the seeming "e-chaos" and progress to sustainable e-health solutions.

Determinants of choice of usual source of care among older people with cardiovascular diseases in China: evidence from the Study on Global Ageing and Adult Health.

BACKGROUND: Cardiovascular diseases (CVD) are emerging as the leading contributor to death globally. The usual source of care (USC) has been proven to generate significant benefits for the elderly with CVD. Understanding the choice of USC would generate important knowledge to guide the ongoing primary care-based integrated health system building in China. This study aimed to analyze the individual-level determinants of USC choices among the Chinese elderly with CVD and to generate two exemplary patient profiles: one who is most likely to choose a public hospital as the USC, the other one who is most likely to choose a public primary care facility as the USC. METHODS: This study was a secondary analysis using data from the World Health Organization's Study on Global AGEing and Adult Health (SAGE) Wave 1 in China. 3,309 individuals aged 50 years old and over living with CVD were included in our final analysis. Multivariable logistic regression was built to analyze the determinants of USC choice. Nomogram was used to predict the probability of patients' choice of USC. RESULTS: Most of the elderly suffering from CVD had a preference for public hospitals as their USC compared with primary care facilities. The elderly with CVD aged 50 years old, being illiterate, residing in rural areas, within the poorest income quintile, having functional deficiencies in instrumental activities of daily living and suffering one chronic condition were found to be more likely to choose primary care facilities as their USC with the probability of 0.85. Among those choosing primary care facilities as their USC, older CVD patients with the following characteristics had the highest probability of choosing public primary care facilities as their USC, with the probability of 0.77: aged 95 years old, being married, residing in urban areas, being in the richest income quintile, being insured, having a high school or above level of education, and being able to manage activities living. CONCLUSIONS: Whilst public primary care facilities are the optimal USC for the elderly with CVD in China, most of them preferred to receive health care in public hospitals. This study suggests that the choice of USC for the elderly living with CVD was determined by different individual characteristics. It provides evidence regarding the choice of USC among older Chinese patients living with CVD.

Assessment of the level and distribution of health system responsiveness in Oyo State, Nigeria.

BACKGROUND: Health systems need to be evaluated to ascertain if they are meeting their objectives. There is an increased interest in health system responsiveness (HSR) as a means to appraise health systems. This becomes vital as we put people at the centre of integrated health systems and put a premium on their rights and perspectives. Thus, this study assessed the levels, distribution and factors associated with HSR in Oyo State. METHODS: The study was a cross-sectional study with 717 adults, who had used an out-patient health facility in the preceding 12 months, interviewed using a semi-structured, interviewer-administered questionnaire. HSR was measured on a multi-domain and multi-item (7 domains and 20 items) 5-point Likert scale that was developed by the WHO to measure HSR globally. Summary scores were computed for level, distribution and the most important domains of HSR. Determinants of poor HSR were determined using binomial logistic regression. The level of statistical significance was set at 5%. RESULTS: The overall level of HSR was 47%. The highest-rated domains were confidentiality (72%), dignity (64%) and choice (60%), while the least rated were prompt attention (43%) and communication (52%). The overall distribution of HSR was 0.228 (range of 0 to 1) with the domains of prompt attention (0.595) and choice (0.506) being the most unequally distributed. The most important domains were communication, prompt attention and dignity. The least important domains were choice and confidentiality. The factors associated with poor HSR (overall) were no formal education, (OR = 2.81; 95% CI: 1.35-5.86), primary education as the highest level of education (OR = 2.19; 95% CI: 1.28-3.75), poor socioeconomic class (OR = 1.86; 95% CI: 1.23-2.80), using a government-owned facility (OR = 1.56; 95% CI: 1.11-2.19) and not using the usual health facility (OR = 1.69; 95% CI: 1.13-2.53). CONCLUSIONS: The overall level of HSR in Oyo State was low with the domains of prompt attention, communication and autonomy being the least rated domains. Therefore, concerted efforts should be targeted at improving HSR as this will improve wellbeing, health system utilization, and the overall health system.

Developing a Risk Reduction Support System for Health System in Iran: A Case Study in Blood Supply Chain Management.

Health systems are recognised as playing a potentially important role in many risk management strategies; however, there is strong evidence that health systems themselves have been the victims of unanticipated risks and have lost their functionality in providing reliable services. Existing risk identification and assessment tools in the health sector, particularly in the blood supply chain, address and evaluate risks without taking into account their interdependence and a holistic perspective. As a result, the aim of this paper is to develop a new systemic framework based on a semi-quantitative risk assessment approach to measure supply chain risks, which will be implemented through a case study on the Iranian BSC. This paper identifies and assesses supply chain risks (SCRs) by employing a novel systemic process known as SSM-SNA-ISM (SSI). First, the supply chain and its risks are identified using Soft Systems Methodology (SSM). Then, given the large number of risks, the second stage uses Social Network Analysis (SNA) to identify the relationships between the risks and select the most important ones. In the third stage, risk levelling is performed with a more in-depth analysis of the selected risks and the application of Interpretive Structural Modelling (ISM), and further analysis is performed using the Cross-Impact Matrix Multiplication Applied to Classification (MICMAC). The study found that by using the new proposed approach, taking into account risk relationships, and taking a holistic view, various supply chain risks could be assessed more effectively, especially when the number of risks is large. The findings also revealed that resolving the root risks of the blood supply chain frequently necessitates management skills. This paper contributes to the literature on supply chain risk management in two ways: First, a novel systemic approach to identifying and evaluating risks is proposed. This process offers a fresh perspective on supply chain risk modelling by utilising systems thinking tools. Second, by identifying Iranian BSC risks and identifying special risks.

Care Considerations in a Patient- and Family-Centered Medical Assistance in Dying Program.

Objective: Medical Assistance in Dying (MAID) became legal in Canada in June 2016. As part of a project designed to improve end-of-life care for those requesting MAID, qualitative data from patients, families, and providers were used to assess opportunities to enhance patient-and family-centered care (PFCC) in this program. Methods: Thirty interviews were conducted with patients, families, and healthcare providers. Five patients who requested an assessment for MAID, 11 family members, and 14 healthcare providers were interviewed about their experiences in 2017. Comparative coding and thematic analysis were completed with the support of NVivo12. Results: Emotional PFCC considerations included: exploring and validating the emotional journey, navigating the uncertain, judgmental experiences, and the emotional impact on families and the care team. Physical PFCC considerations included: sensitivity in eligibility assessments, weaving in interdisciplinary care, provision of anticipatory guidance, and death location. Spiritual PFCC considerations included: honoring choice, listening to life stories, supporting spiritual needs, and acknowledging loss. Relational PFCC considerations included: defining the circle of support, supporting the circle, and relational investments. Conclusion: Fundamental to a PFCC MAID program, practitioners must be afforded time to provide holistic care. Program-related suggestions include incorporating interdisciplinary care early, and throughout the illness trajectory, consistency in care providers, appropriate anticipatory guidance, and bereavement supports for family, and dedicate space for MAID provisions. Patients and families must be included in the ongoing development and re-evaluation of MAID programs to ensure continued focus on quality end-of-life care.

Exploring key stakeholders' attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol.

INTRODUCTION: Canadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies and recommended practices regarding the optimal relationship between MAiD and PC services are not well developed. Multiple models are possible, including autonomous delivery of these services and formal or informal coordination, collaboration or integration. However, it is not clear which of these approaches are most appropriate, feasible or acceptable in different Canadian health settings in the context of the COVID-19 pandemic and in the post-pandemic period. The aim of this qualitative study is to understand the attitudes and opinions of key stakeholders from the government, health system, patient groups and academia in Canada regarding the optimal relationship between MAiD and PC services. METHODS AND ANALYSIS: A qualitative, purposeful sampling approach will elicit stakeholder feedback of 25-30 participants using semistructured interviews. Stakeholders with expertise and engagement in MAiD or PC who hold leadership positions in their respective organisations across Canada will be invited to provide their perspectives on the relationship between MAiD and PC; capacity-building needs; policy development opportunities; and the impact of the COVID-19 pandemic on the relationship between MAiD and PC services. Transcripts will be analysed using content analysis. A framework for integrated health services will be used to assess the impact of integrating services on multiple levels. ETHICS AND DISSEMINATION: This study has received ethical approval from the University Health Network Research Ethics Board (No 19-5518; Toronto, Canada). All participants will be required to provide informed electronic consent before a qualitative interview is scheduled, and to provide verbal consent prior to the start of the qualitative interview. Findings from this study could inform healthcare policy, the delivery of MAiD and PC, and enhance the understanding of the multilevel factors relevant for the delivery of these services. Findings will be disseminated in conferences and peer-reviewed publications.

Characterizing patient assistance program use and patient responsiveness to specialty drug price for multiple sclerosis in a mid-size integrated health system.

BACKGROUND: There is concern that increasingly common use of patient assistance programs (PAPs), out-of-pocket assistance provided by manufacturers or foundations, distorts our understanding of patient behavior and insurance design incentives. Yet the current literature on prescription drug cost sharing largely overlooks their use. PAPs prevalence and impact on drug demand and price elasticity is a major knowledge gap. OBJECTIVE: To examine the use of PAPs among patients with multiple sclerosis (MS) and the association with drug demand in a specialty pharmacy program within a regional integrated health system that facilitates their use. METHODS: We used pharmaceutical claims data from December 2017 to December 2018 linked to detailed payer information from Kaiser Permanente Washington to characterize the prevalence of PAPs for users of 7 MS specialty drug molecules. We estimated price elasticity of demand (PED) in a two-part model by using the presence of copayment assistance as a source of cost variation. The first part estimated marginal probability of a claim in a given month with a probit model, comparing PAP users and nonusers, whereas the second part estimated days supplied of a medication, given a claim was made as a measure for demand. RESULTS: Of 789 unique patients, 480 (60.7%) used PAPs in at least 1 drug claim during the 13-month time frame, and 248 patients (31.4%) used PAPs for all of their MS drug claims. When used, copay assistance covered 100% of out-of-pocket (OOP) charges for 98% of claims and reduced patient annual OOP cost by $3,493 on average. People who used PAPs had much higher OOP charges, a lower Charlson comorbidity score, and were more likely to have insurance through an exchange. The OOP costs charged to patients was higher for claims where patient assistance was used than claims where assistance was not used ($294 vs $42, P < 0.001). Total claim amount was higher for claims that used assistance ($6,169) than claims that did not ($5,503, P < 0.001). The probability of a patient having a drug claim in a given month was 1.9% higher among those using patient assistance, although this finding was not significant (P = 0.258). An average change in price of -$168.21 with PAP use led to an average change in demand of -0.05 days, for an overall price elasticity of demand (SD = 0.028, P = 0.852) given PAP use of 0.005, indicating that the presence of PAPs did not significantly affect demand. PED estimates were not statistically significant by drug, and the exclusion of Medicare patients did not change this interpretation. CONCLUSIONS: In a mid-size integrated health system in the state of Washington, a program that promotes adherence to specialty drugs via facilitated PAP use was found to reduce patient OOP costs but had no effect on prescription drug utilization. Payers may consider embracing PAPs to remove patient financial barriers to necessary medications and use tools other than cost sharing to influence patient consumption of specialty drugs. DISCLOSURES: This manuscript was funded in part through a Pre-Doctoral Fellowship in Health Outcomes from the PhRMA Foundation awarded to Brouwer for the completion of her dissertation work. Yeung receives some salary support from Kaiser Permanente. The other authors have nothing to disclose.

Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting: a qualitative descriptive study.

BACKGROUND: Rapid implementation of Medical Assistance in Dying (MAiD) across care settings has challenged providers and organizations, including hospices, to develop and implement new modes of practice. The aim of this study was to examine the effects that legalization of MAiD has had on hospice care provider roles within the non-provider context. METHODS: Eight in-depth semi-structured interviews were conducted and a qualitative descriptive approach used to examine hospice care providers experiences in a small western Canadian city. In the study context, patients who choose MAiD are cared for until immediately prior to the procedure when they are transferred off-site to undergo MAiD. Inductive and thematic analyses were undertaken. RESULTS: Participants experienced practical, philosophical, and professional challenges. Despite the overwhelming desire to support patient autonomy and decision-making, some interpreted patient choice for MAiD as rejection of the natural death experience at the hospice. Patient choice for MAiD initiated a new and different pathway of end-of-life care. While participants felt uncertain how best to support patients undergoing MAiD, they shared mixed optimism on how their care provider roles were evolving as their level of experience broadened. While implementation of MAiD was rapid, the introduction of practical and professional supports has remained slow to materialize, leaving many providers to navigate their own personal and professional positions and practices. CONCLUSION: Care providers require a multi-faceted range of clinical, legal, and logistical supports at the practice, organizational, and health system levels, to facilitate care delivery to those requesting and undergoing MAiD and to promote coordinated and holistic patient-centered care. The different pathway for those who chose MAiD may lead care providers to struggle with relational challenges and interpersonal unease. Further research may address how to support those undergoing MAiD within the hospice context.

Comparison of out-of-pocket expenditure and catastrophic health expenditure for severe disease by the health security system: based on end-stage renal disease in South Korea.

BACKGROUND: Korea's health security system named the National Health Insurance and Medical Aid has revolutionized the nation's mandatory health insurance and continues to reduce excessive copayments. However, few studies have examined healthcare utilization and expenditure by the health security system for severe diseases. This study looked at reverse discrimination regarding end-stage renal disease by the National Health Insurance and Medical Aid. METHODS: A total of 305 subjects were diagnosed with end-stage renal disease in the Korea Health Panel from 2008 to 2013. Chi-square, t-test, and ANCOVA were conducted to identify the healthcare utilization rate, out-of-pocket expenditure, and the prevalence of catastrophic expenditure. Mixed effect panel analysis was used to evaluate total out-of-pocket expenditure by the National Health Insurance and Medical Aid over a 6-year period. RESULTS: There were no significant differences in the healthcare utilization rate for emergency room visits, admissions, or outpatient department visits between the National Health Insurance and Medical Aid because these healthcare services were essential for individuals with serious diseases, such as end-stage renal disease. Meanwhile, each out-of-pocket expenditure for an admission and the outpatient department by the National Health Insurance was 2.6 and 3.1 times higher than that of Medical Aid (P < 0.05). The total out-of-pocket expenditure, including that for emergency room visits, admission, outpatient department visits, and prescribed drugs, was 2.9 times higher for the National Health Insurance than Medical Aid (P < 0.001). Over a 6-year period, in terms of total of out-of-pocket expenditure, subjects with the National Health Insurance spent more than those with Medical Aid (P < 0.01). If the total household income decile was less than the median and subjects were covered by the National Health Insurance, the catastrophic health expenditure rate was 92.2%, but it was only 58.8% for Medical Aid (P < 0.001). CONCLUSION: Individuals with serious diseases, such as end-stage renal disease, can be faced with reverse discrimination depending on the type of insurance that is provided by the health security system. It is necessary to consider individuals who have National Health Insurance but are still poor.

Inclusion in limited distribution drug network reduces time to dalfampridine access in patients with multiple sclerosis at a health-system specialty pharmacy.

BACKGROUND: Dalfampridine improves walking speed in patients with multiple sclerosis (MS), but accessing specialty medications such as dalfampridine can be hindered by insurance restrictions, high costs, and limited distribution networks (LDNs) imposed by manufacturers. Some integrated health-systems specialty pharmacies (HSSPs) embed pharmacists in clinics and dispense medications from their internal pharmacies if included within the LDN. OBJECTIVE: To assess access to dalfampridine in patients at an HSSP before and after gaining admission to the LDN. METHODS: This study was conducted at Vanderbilt Specialty Pharmacy (VSP), an integrated HSSP at Vanderbilt University Medical Center (VUMC) with 2 clinical pharmacists embedded in the MS clinic. VSP gained access to the dalfampridine LDN on May 1, 2018, at which time the embedded pharmacists began to manage the comprehensive therapy initiation process. We performed a retrospective review of adult patients with MS who were prescribed dalfampridine from March 2010 to December 2018. Eligible prescriptions were new starts (no previous use) or restarts (after previous use and discontinuation). Prescriptions were classified as pre-VSP and post-VSP, which differentiates before and after VSP gained access to dispense dalfampridine. Study outcomes were insurance approval, initiation of therapy, and time from treatment decision to medication access. We used a proportional odds logistic regression model for time to medication access using the following covariates: pre-VSP versus post-VSP time period, insurance prior authorization (PA) denied versus approved/not needed, and baseline timed 25-foot walk. RESULTS: We included 262 patients and 290 prescriptions (260 pre-VSP and 30 post-VSP). In pre-VSP and post-VSP prescriptions, 97% were approved by insurance, and 93% of patients started therapy. Median time to medication access was 22 days (IQR = 11-45) for pre-VSP prescriptions and 1 day (IQR = 0-3) for post-VSP prescriptions. In the proportional odds logistic regression model, the odds of having a longer medication access time were significantly higher for pre-VSP prescriptions (OR = 83.219, P < 0.001) and prescriptions whose PA was initially denied (OR = 9.50, P < 0.001); 25-foot walk time was not significant (OR = 0.95, P = 0.277). CONCLUSIONS: After obtaining access to dispense dalfampridine, the time to access therapy was reduced, suggesting that LDNs delay patient access to therapy at HSSPs. DISCLOSURES: No funding was provided for this study. The authors have no conflicting interests to disclose. Preliminary results have been previously presented at the American Society of Health-Systems Pharmacy Midyear Meeting in December 2019, the Vanderbilt Health Systems Specialty Pharmacy Outcomes Research Summit in August 2020, and the National Association of Specialty Pharmacy Annual Meeting in September 2020.

COVID-19 Home Monitoring After Diagnosis and Health Care Utilization in an Integrated Health System.

This cohort study examines health care utilization patterns for patients with COVID-19 who were enrolled vs not enrolled in a home monitoring program.

The effects of expanded social health insurance on young mothers: Lessons from a pro-choice reform in Uruguay.

With the implementation of the National Integrated Health System in 2007, the Uruguayan government extended social health insurance (SHI) to groups of individuals previously covered by the public safety net (PSN) or that paid for private insurance out-of-pocket. The policy allowed new beneficiaries to choose care from a set of private providers. In this study, we focus on the extension of SHI to adolescent mothers previously covered by the PSN. Exploiting the gradual incorporation of children of formal workers during the 2008-2013 period, and the geographic variation in the intensity of the reform, we find suggestive evidence that the increase in choice associated to the expansion of SHI decreased adolescent fertility, improved prenatal care and birthweight, and decreased first year mortality among low birthweight infants. These effects were only observed in the medium run, suggesting initial choice frictions and input shortage. We provide evidence that families increased their choice of private providers and that market concentration decreased in certain areas of the country, supporting the hypothesis that choice, and possibly competition, were the main mechanisms behind the findings.

Hospice Palliative Care (HPC) and Medical Assistance in Dying (MAiD): Results From a Canada-Wide Survey.

BACKGROUND: With the legalization of medical assistance in dying (MAiD) in Canada, physicians and nurse practitioners now have another option within their scope of practice to consider alongside hospice palliative care (HPC) to support the patient and family regardless of their choice toward natural or medically assisted death. To elucidate insights and experiences with MAiD since its inception and to help adjust to this new end-of-life care environment, the membership of the Canadian Hospice Palliative Care Association (CHPCA) was surveyed. METHODS: The CHPCA developed and distributed a 16-item survey to its membership in June 2017, one year following the legalization of MAiD. Data were arranged in Microsoft® Excel and open-ended responses were analyzed thematically using NVivo 12 software. RESULTS: From across Canada, 452 responses were received (response rate: 15%). The majority of individuals worked as nurses (n = 161, 33%), administrators (n = 79, 16%), volunteers (n = 76, 16%) and physicians (n = 56, 11%). Almost 75% (n = 320) of all respondents indicated that they had experienced a patient in their program who had requested MAiD. Participants expressed dissatisfaction with the current psychological and professional support being provided by their health care organization and Ministry of Health - during and after the MAiD procedure. CONCLUSION: The new complexities of MAiD present unique challenges to those working in the health-care field. There needs to be an increased focus on educating/training providers as without proper support, health-care workers will be unable to perform to their full potential/scope of practice while also providing patients with holistic and accessible care.

Medical assistance in dying: just an ethical or legal issue?

According to current vital statistics suicide appears as a growing public health problem in most Western countries. However, suicide is rarely discussed in scientific journals, possibly because of a persisting moral stigma. As a consequence, the diverse bases of suicidal behavior are little understood while the role of Chronic-Degenerative Terminal Diseases (CDTD) has been poorly investigated. In the present study, the topic of suicidality was addressed in a clinical, holistic, perspective in an attempt to clarify how, in some chronically ill patients, the decision to end their own life is taken independently from mental disorders, being conversely, the expression of a rational psychological pattern which copes with the burden of chronic illnesses to become an integral part of their clinical spectrum. An assisted suicide (AS) request should therefore be considered from a clinical point of view and not only as an ethical or legal issue, in fact a holistic evaluation of the patient's situation must be performed, conferring the decisions making process a further in-depth line of thinking. In this study we first examined the relationship between suicide and CDTD as reported in the medical literature; then we reviewed the psychological theories which allegedly explain suicidal behavior; finally we discussed the possible role of a full-fledged palliative care in preventing suicide and in managing death requests by CDTD patients.

Nutritional status coverage trend registered in the SISVAN web in seven municipalities of the Zona Da Mata Mineira, Brazil, from 2008 to 2017, and its association with socio-economic, demographic and organisation of health system variables.

We analysed the coverage trend of the evaluation of the nutritional status of users of public health services registered in the Food and Nutrition Surveillance System (SISVAN) between 2008 and 2017 in seven municipalities and verified the association of the coverage trend with the socio-economic, demographic and organisational aspects of health system variables. It is an ecological time-series study performed with secondary data extracted from health information systems. Descriptive statistics, linear regression model and repeated measures analysis were performed. The coverage of evaluation of nutritional status was low over the period. Five municipalities showed a tendency to increase coverage, although small, while two remained stable. The highest annual variation in coverage increase was concentrated in the group of pregnant women and the lowest in adolescents and older adults. There was a downward trend in follow-ups from the Bolsa Family Programme and a trend towards increased follow-ups from SUS Primary Care (e-SUS AB). SISVAN coverage was positively associated with the proportion of rural population (P ≤ 0·001) and coverage of community health agents (P < 0·001); and negatively associated with total population (P < 0·001), demographic density (P = 0·006) and gross domestic product per capita (P = 0·008). Despite the tendency to increase coverage in some municipalities, SISVAN still presents low coverage of nutritional status assessment, which compromises population monitoring. Knowing the factors that influence the coverage can subsidise the elaboration of strategies for its expansion.

Implementation of altered provider incentives for a more individual-risk-based assignment of dental recall intervals: evidence from a health systems reform in Denmark.

Equipping health systems with suitable incentives for efficient resource allocation remains a major health policy challenge. This study examines the impacts of 2015 regulatory changes in Danish dental care which aimed at effectuating a transition from six-to-twelve-monthly dental recall intervals, for every patient, towards a model where patients with higher need receive dental recalls systematically more frequently than patients with lower need. Exploiting administrative data from the years 2012-2016 from the Danish National Health Insurance database containing 72,155,539 treatment claims for 3,759,721 unique patients, we estimated a series of interrupted time-series regression models with patient-level fixed-effects. In comparison to the pre-reform period, the proportion of patients with recall intervals of up to 6 months was by 1.2%-points larger post-implementation; that of patients with 6-12-monthly recalls increased by 0.7%-points; that of patients with more than 12-monthly dental recalls decreased by 1.9%-points. The composition of care shifted more substantially: the proportion of treatment sessions including preventive care increased by 31.5%-points (95%-CI: 31.4;31.6); that of sessions including scaling increased by 24.1%-points (24.0;24.2); that of sessions including diagnostics decreased by 34.5%-points (34.4;34.6). These findings suggest that dental care providers may have responded differently to regulatory changes than intended by the health policy.