RESUMO
Ontario cancer patients' monthly out-of-pocket costs (OOPC) were assessed to determine whether these costs were problematic. A self-administered questionnaire was administered to breast (n = 74), colorectal (n = 70), lung (n = 68) and prostate (n = 70) cancer patients between October 2001 and April 2003. It measured categorical OOPC, which were analysed using linear regression modelling, to determine whether any of a variety of independent variables influenced OOPC. Monthly OOPC (mean, range) were: parking/fares ($47, $0-450), devices ($46, $0-2350), prescription drugs ($45, $0-1400), accommodation ($43, $0-1500), complementary and alternative medicine ($29, $0-5000), vitamins ($25, $0-400), homemaking ($14, $0-1000), family care ($12, $0-1200), homecare ($2, $0-330) and other ($8, $0-250), with the total averaging $213 ($0-5230). Imputed travel mileage costs added $372 ($0-6180). Most patients were well served by the current healthcare programmes. In multivariate analysis, variables influencing several OOPC categories were: tumour site, hospitalization, age, and number of clinic trips. Travel costs proved the most problematic, with patients under 65 years and without insurance more likely to have high OOPC. Education and income were not reliable predictors for high OOPC. Many of these costs were for items not traditionally covered by public healthcare financing systems, raising important issues around defining 'medically necessary' care and the role of government.
Assuntos
Efeitos Psicossociais da Doença , Financiamento Pessoal/estatística & dados numéricos , Neoplasias/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cuidadores/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Fatores Socioeconômicos , Inquéritos e Questionários , Viagem/economiaRESUMO
The objective of this study was to determine if complementary and alternative medicine (CAM) Users are more autonomous than Non-Users with respect to their preferred role in decision-making (measured by the problem-solving decision-making or PSDM scale). A survey was mailed in spring 2001 to a random sample of 696 men (selected from the Ontario Cancer Registry), aged 18 years or older and diagnosed with prostate cancer in the preceding 2 years. Less than 5% of the 489 (72.1% response rate) men (mean age 68.6 years) who responded to the PSDM question in our survey were classified as having an autonomous role preference, while almost 1/3 of the respondents reported using CAM for their prostate cancer. The majority of respondents were classified as preferring a shared role and a substantial minority was classified as preferring a passive role. There was no statistically significant difference between CAM users and non-users with respect to their preferred role. The hypothesis that CAM Users are more autonomous problem solvers and decision makers is not supported by these findings; however, the generalizability of our results is limited by the fact that we surveyed a relatively older male population only.
Assuntos
Terapias Complementares/psicologia , Tomada de Decisões , Resolução de Problemas , Idoso , Humanos , Masculino , Participação do Paciente/psicologia , Neoplasias da Próstata/terapiaRESUMO
OBJECTIVE: To determine the preferred role in medical decision making of women undergoing fertility treatments and to establish whether their knowledge of treatments is adequate to inform their choices. METHODS: Self-report survey of 404 women undergoing fertility treatments in 2 university hospitals and a private fertility clinic in Canada. RESULTS: The women had been in fertility treatment for 2.3 +/- 2.6 years; 67.8% reported taking fertility drugs. Most (61.7%) women wanted to share knowledge equally with their doctors about possible fertility treatments. However, about half wanted to decide alone or mostly by themselves about the acceptability of treatment risks and benefits (56%), what treatments should be selected (49.8%), and when to conclude treatments (54.3%). In addition, 55.1% of the women did not know their personal eventual chances of pregnancy with fertility treatment or thought it was 50% or greater. Over half of the women (57.2%) who had taken fertility drugs were unaware of a possible link between fertility drugs and increased ovarian cancer risk. The majority of women (61.8%) who knew of this possible association reported that they learned about it from the print media. Women who knew of the association had a poor understanding of the strength of the evidence or the ability to detect or treat ovarian cancer successfully, and 88.3% thought they could reduce cancer risk by following their doctors' advice. CONCLUSIONS: Despite these women's wishes to actively participate in fertility treatment decisions, they lacked the necessary information to do so meaningfully. Public health policymakers, professional and advocacy organizations, physicians, other healthcare providers, and women themselves must find ways to improve the general public's and patients' understanding about fertility treatment outcomes and risks.
Assuntos
Infertilidade Feminina/terapia , Participação do Paciente , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Inquéritos e QuestionáriosRESUMO
Restructuring, particularly redeployment and job change, had a dramatic impact on the working conditions and practices of nursing personnel. This study was conducted to determine whether nurses (RNs and RPNs) who experienced job change perceived their work-lives differently than those who did not undergo job change and, whether nurses who experienced different types of job change (new role, new unit, or new hospital) varied in their perceptions. A questionnaire exploring themes relevant to redeployment was administered to all nurses (N = 3,408) in two large teaching hospitals that had undergone restructuring. The response rate was 50.7% (n = 1,728). Of the responses, 1,662 were used in the analysis. T-tests and ANOVAs were used to compare groups of nurses. Nurses who changed their jobs perceived their commitment to the organization, their work environment and quality of care differently than those who did not change jobs. Nurses with different types of job change differed in their organizational commitment, perceptions of work-related injuries, attitudes towards job change, need for orientation and new knowledge, and feelings about the health care team. Results will assist managers to address the specific needs of nurses with different experiences of job change in the restructured workplace.
Assuntos
Atitude do Pessoal de Saúde , Reestruturação Hospitalar/organização & administração , Descrição de Cargo , Papel do Profissional de Enfermagem/psicologia , Recursos Humanos de Enfermagem Hospitalar/psicologia , Adulto , Análise de Variância , Feminino , Hospitais de Ensino , Humanos , Satisfação no Emprego , Masculino , Pesquisa Metodológica em Enfermagem , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Ontário , Inovação Organizacional , Lealdade ao Trabalho , Inquéritos e Questionários , Carga de Trabalho , Local de Trabalho/organização & administração , Local de Trabalho/psicologiaRESUMO
OBJECTIVE: To determine the effect of the Ischemic Heart Disease Shared Decision-Making Program (IHD SDP) an interactive videodisc designed to assist patients in the decision-making process involving treatment choices for ischemic heart disease, on patient decision-making. DESIGN: Randomized, controlled trial. SETTING: The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada. PARTICIPANTS: Two hundred forty ambulatory patients with MEASUREMENTS AND MAIN RESULTS: The primary outcome was patient satisfaction with the decision-making process. This was measured using the 12-item Decision-Making Process Questionnaire that was developed and validated in a randomized trial of the benign prostatic hyperplasia SDP. Secondary outcomes included patient knowledge (measured using 20 questions about knowledge deemed necessary for an informed treatment decision), treatment decision, patient-angiographer agreement on decision, and general health scores. Outcomes were measured at the time of treatment decision and/or at 6 months follow-up. Shared decision-making program scores were similar for the intervention and control group (71% and 70%, respectively; 95% confidence interval [CI] for 1% difference, -3% to 7%). The intervention group had higher knowledge scores (75% vs 62%; 95% CI for 13% difference, 8% to 18%). The intervention group chose to pursue revascularization less often (58% vs 75% for the controls; 95% CI for 17% difference, 4% to 31%). At 6 months, 52% of the intervention group and 66% of the controls had undergone revascularization (95% CI for 14% difference, 0% to 28%). General health and angina scores were not different between the groups at 6 months. Exposure to the IHD SDP resulted in more patient-angiographer disagreement about treatment decisions. CONCLUSIONS: There was no significant difference in satisfaction with decision-making process scores between the IHD SDP and usual practice groups. The IHD SDP patients were more knowledgeable, underwent less revascularization (interventional therapies), and demonstrated increased patient decision-making autonomy without apparent impact on quality of life.
Assuntos
Técnicas de Apoio para a Decisão , Isquemia Miocárdica/terapia , Gravação de Videodisco , Intervalos de Confiança , Angiografia Coronária , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Ontário , Satisfação do Paciente , Estatísticas não Paramétricas , Inquéritos e QuestionáriosAssuntos
Reforma dos Serviços de Saúde , Programas Nacionais de Saúde/organização & administração , Canadá , Documentação , Estudos de Avaliação como Assunto , Publicações Governamentais como Assunto , Alocação de Recursos para a Atenção à Saúde , Gastos em Saúde , Programas Nacionais de Saúde/economia , Sistema de Fonte Pagadora Única , Responsabilidade SocialRESUMO
How realistic are proposals to expand the financing of Canadian health care through private insurance, either in a parallel stream or an expanded supplementary tier? Any successful business requires that revenues exceed expenditures. Under a voluntary health insurance plan those at highest risk would be the most likely to seek coverage; insurers working within a competitive market would have to limit their financial risk through such mechanisms as "risk selection" to avoid clients likely to incur high costs and/or imposing caps on the costs covered. It is unlikely that parallel private plans will have a market if a comprehensive public insurance system continues to exist and function well. Although supplementary plans are more congruous with insurance principles, they would raise costs for purchasers and would probably not provide full open-ended coverage to all potential clients. Insurance principles suggest that voluntary insurance plans that shift costs to the private sector would damage the publicly funded system and would be unable to cover costs for all services required.
Assuntos
Financiamento Pessoal , Seguro Saúde/economia , Canadá , Custos de Cuidados de Saúde/tendências , Acessibilidade aos Serviços de Saúde , Humanos , Setor Privado , Gestão de Riscos , Medicina Estatal/economiaRESUMO
What do insurers and employers feel about proposals to expand Canadian health care financing through private insurance, in either a parallel stream or a supplementary tier? The authors conducted 10 semistructured, open-ended interviews in the autumn and early winter of 1996 with representatives of the insurance industry and benefits managers working with large employers; respondents were identified using a snowball sampling technique. The respondents felt that proposals for parallel private plans within a competitive market are incompatible with insurance principles, as long as a well-functioning and relatively comprehensive public system continues to exist; the maintenance of a strong public system was both socially and economically desirable. With the exception of serving the niche market for the private management of return-to-work strategies, respondents showed little interest in providing parallel coverage. They were receptive to a larger role for supplementary insurance but cautioned that they are not willing to cover all delisted services. As business executives they stated that they are willing to insure only services and clients that will be profitable.
Assuntos
Financiamento Pessoal , Seguro Saúde/economia , Canadá , Competição Econômica , Indústrias , Marketing de Serviços de Saúde , Setor PrivadoRESUMO
There are different ways to measure how much Canada spends on health care and the quality of these measurements may vary. This paper examines Organization for Economic Cooperation and Development data for 3 common standards of measure: health expenditures as a proportion of gross domestic product (GDP), nominal spending per capita (US dollars) and spending per capita in purchasing power parities (PPP) equivalents. In 1994, the most recent year for which there were firm data. Canada spent 9.9% of its GDP on health care (rank 3 of 29), and $1999 PPPs per capita (rank 3). However, actual spending was only US$1824 per capita (rank 14). In the same year Japan spent 7% of GDP on health care (rank 22), $1478 in PPPs per capita (rank 16), but actually spent US$2614 per capita (rank 3). Although each measure is suitable for some policy purposes, Canadian spending remains modest by international standards.
Assuntos
Gastos em Saúde/estatística & dados numéricos , Canadá , Coleta de Dados , Europa (Continente) , Humanos , Japão , Estados UnidosRESUMO
OBJECTIVES: To determine patient views about the Shared Decision-Making Program (SDP), an interactive videodisk program designed to inform patients with benign prostatic hyperplasia (BPH) about their condition and treatment options and to determine its impact on perceived knowledge and treatment preference. METHODS: Six hundred seventy-eight patients with symptomatic BPH from eight Canadian centers viewed the SDP. Before and after viewing the video, patients answered questionnaires designed to assess treatment preference, knowledge gained, and satisfaction with this educational format. A 1-year follow-up survey was also conducted. RESULTS: Most patients showed a high desire for information and high satisfaction with the SDP; this satisfaction persisted at 1 year. Patients' self-reported knowledge increased significantly (P <0.0001). However, the SDP did not alter initial treatment preferences among those with already formed preferences, although it aided almost half of those initially undecided in forming a preference. Viewing the SDP also appeared to enhance the physician-patient relationship. CONCLUSIONS: Patients saw the SDP as an effective method for teaching patients about BPH and the risks and benefits of various treatments, clarifying particular areas about which many patients appear to have a desire for more information than is often provided. Patients were enthusiastic about the educational value of the program, and their active participation in the decision-making process may actually enhance the physician-patient relationship. Contrary to other studies, we found no significant alterations in treatment preferences. Problems relating to the cost and timely updating of the software need to be addressed for these kinds of programs to realize their full potential.
Assuntos
Participação do Paciente , Avaliação de Programas e Projetos de Saúde , Hiperplasia Prostática/terapia , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inquéritos e QuestionáriosRESUMO
Decision making is a fundamental element of nursing work, one that is essential to understand as organizations explore cost effective ways to deliver quality health care. While the importance of decision making has been well articulated, previous descriptions of nursing work have had difficulty describing completely this cognitive component. This paper identifies critical elements within the process of nursing decision making that have not been addressed adequately within current decision making frameworks. In this exploratory research, nursing personnel described their work; qualitative content analysis was used to categorize components of nursing decision making within these descriptions. Revealed are complex nursing decisions that occur after the selection of nursing intervention, and prior to the implementation of that intervention. These decisions address the complex network of interactions involved with enactment of the nursing role, the repertoire of leadership skills such as collaboration, negotiation, and delegation required to elicit the involvement of other individuals; discretionary decisions made in the allocation of resources; priority setting; and strategizing. These findings have implications for nursing competency and quality of care, cost-effective delivery of health care, and nursing education.
Assuntos
Atitude do Pessoal de Saúde , Tomada de Decisões , Descrição de Cargo , Processo de Enfermagem , Recursos Humanos de Enfermagem/psicologia , Competência Clínica , Análise Custo-Benefício , Grupos Focais , Humanos , Pesquisa Metodológica em Enfermagem , Recursos Humanos de Enfermagem/educação , Qualidade da Assistência à SaúdeRESUMO
In the debate about the role of health professionals, two normative models have been placed in opposition - 'care vs. cure'. To many, the cure model has been associated with physicians, and the care model with nursing and the other allied health professions. As the shortcomings of a cure-orientated model have been recognized, particularly in dealing with chronic disease, more attention has been focused on care, with many writing as though the two were mutually exclusive. In this paper, we suggest that these models are instead end-points on a continuum which ideally should be used by all health providers, rather than being characteristic of different clinical professionals. This conceptualization places less concern on what should be done by doctors as opposed to nurses, and more on the needs of the particular situation. The resulting convergence among roles should not imply that nursing and the allied health professions will adopt the medical model, but that medicine, nursing and others will work together with patients for all members' mutual benefit. In this expanded continuum, the focus for decision making becomes the patient and family in partnership and collaboration with health professionals.
Assuntos
Atenção à Saúde , Empatia , Relações Interprofissionais , Modelos de Enfermagem , Papel do Profissional de Enfermagem , Enfermeiras e Enfermeiros , Médicos , Humanos , OntárioRESUMO
PURPOSE: To describe the public health systems and their projected futures in six provinces in the context of two developments: 1) the emerging discourse on population health and 2) the trend toward regionalization of the health care system. METHODS: Telephone interviews with key informants and key document review. RESULTS AND CONCLUSIONS: Communicable disease control and health protection are currently the "core businesses" of public health; the population health discourse has not resulted in mandated programming. The reality is a retrenchment of public health scope during a time that should be considered conducive to expansion. Only Ontario has not regionalized its health care system, although public health is already delivered regionally. Alberta, Saskatchewan and Manitoba have either evolved or are evolving toward an integrated health system. There were concerns about the potential impact on public health identity and funding of this "vertical integration". Regionalization of public health may result in units that are too small to support adequate local expertise and may jeopardize development and enforcement of province-wide programs.
Assuntos
Planejamento em Saúde Comunitária , Prestação Integrada de Cuidados de Saúde/organização & administração , Administração em Saúde Pública/normas , Programas Médicos Regionais/organização & administração , Canadá , Previsões , Necessidades e Demandas de Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Administração em Saúde Pública/tendências , Inquéritos e QuestionáriosRESUMO
While technology assessment is seen as a mechanism for achieving effective and efficient use of health care resources, it has not as yet made the impact on policy decisions that its potential would suggest. Considerable barriers have been encountered in translating assessment results into policy concerning the adoption and use of technologies, with 'political' factors often being decisive. This paper places technology assessment in the content of the policy process to clarify both (a) how conflicting interests and organizational features can often hinder the selection of optimal policies, and (b) the potential roles technology assessment could nonetheless play. The resulting framework is termed the 'rational-political' model of policy development. The paper uses the example of policy making about the regulation of biotechnology, drawing on information from a survey of decision-makers (n = 561) involved in issues concerning the development, approval, and payment for pharmaceutical products.
Assuntos
Biotecnologia/legislação & jurisprudência , Política de Saúde/legislação & jurisprudência , Formulação de Políticas , Avaliação da Tecnologia Biomédica/legislação & jurisprudência , Tecnologia Farmacêutica/legislação & jurisprudência , Biotecnologia/normas , Biotecnologia/tendências , Canadá , Coleta de Dados , Tomada de Decisões Gerenciais , Governo , Humanos , Reembolso de Seguro de Saúde , Avaliação da Tecnologia Biomédica/economia , Transferência de Tecnologia , Tecnologia Farmacêutica/economia , Tecnologia Farmacêutica/normas , Estados UnidosAssuntos
Atenção à Saúde/organização & administração , Setor Privado , Setor Público , Canadá , Atenção à Saúde/economia , Estudos de Avaliação como Assunto , Apoio Financeiro , Governo , Alocação de Recursos para a Atenção à Saúde , Hospitais Privados , Hospitais Públicos , Afiliação Institucional , Organizações sem Fins Lucrativos , Competência ProfissionalAssuntos
Serviços de Saúde Comunitária/organização & administração , Reforma dos Serviços de Saúde/organização & administração , Programas Nacionais de Saúde/organização & administração , Programas Médicos Regionais/organização & administração , Canadá , Necessidades e Demandas de Serviços de Saúde , HumanosRESUMO
In an effort to maintain fiscal viability, hospitals have been undergoing major restructuring. This article reports on a study that examined innovative downsizing strategies used by 20 acute care hospitals in Ontario. The study team reviewed hospital operating plans and analysed the results of interviews conducted with administrators and employees about the downsizing process. Results revealed no uniformity of approach to downsizing. Although many administrators expressed the need for a cooperative approach, downsizing was typically conducted in a top down fashion, and was perceived very differently by staff and administrators. The authors suggest ways to improve restructuring efforts and put forward questions to guide future research.