Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.

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.

Who cares? Who cures? The ongoing debate in the provision of health care.

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.

Public health in Canada: a comparative study of six provinces.

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.

What role do patients wish to play in treatment decision making?

BACKGROUND: Although current ideology suggests patients should be active participants in decision making about their care, the literature suggests that patients wish to be informed but not involved. OBJECTIVE: To test the hypothesis that most patients want their physicians to take the responsibility for problem solving (PS, identifying the one right answer), but that many want to be involved in decision-making (DM, selecting the most desired bundle of outcomes) tasks. METHODS: Survey responses from 300 patients undergoing angiogram at a Toronto, Ontario, hospital were analyzed (response rate, 72%). Survey items included scales to measure desire for information and participation, including Autonomy Preference Index, the Krantz Health Opinion Survey, and the Deber-Kraetschmer Problem-Solving Decision-Making Scale measured on a scale from, 1 (doctor only) to 5 (patient only). RESULTS: Patients had a relatively high desire for information. On the Problem-Solving Decision-Making Scale, they overwhelmingly wished the PS tasks to be performed by or shared with the physician (98.4% of the 12 PS scores are between 1 and 3), but wanted to be involved in DM (78% of the 6 DM scores are between 3 and 5). Preference for handing over control to the physician was significantly greater for the vignette involving potential mortality (chest pain) than for the vignettes involving mainly morbidity (urinary problems) or quality of life (fertility). CONCLUSIONS: Although patients do not wish to be involved in PS tasks, few wish to hand over DM control to their physician. These findings suggest 2 major roles for clinicians--assisting patients in PS to structure choices and supporting them in making often difficult decisions.

Competency assessments: perceptions at follow-up.

OBJECTIVES: To report on the perceptions of assessment of competency and its consequences on a group of clients and significant others at follow-up. METHODS: Ninety-five interviews were conducted using a carefully developed semistructured telephone interview of 24 clients and 71 family/caregivers, representing the perceptions of about 80 clients. RESULTS: There was general satisfaction in the competency assessment process. There was a perception that interests and rights were protected. Clients were seen to be less involved in all spheres of decision making regardless of capacity outcome. Clients and families were satisfied with how decisions were made. CONCLUSIONS: Follow-up study of competency assessment does not support the conclusions previously drawn based on court record studies that assessments are deleterious and frequently result in violations of rights.

Physicians in health care management: 8. The patient-physician partnership: decision making, problem solving and the desire to participate.

How reasonable are expectations that patients will participate in care decisions? The previous article in this series reviewed models of the patient-physician relationship and views on the extent to which patients want to be informed; it also described one information tool--the interactive videodisc. This article reviews literature on the extent to which patients wish to be involved in making decisions about their care. Neither "sensitive paternalism" nor "informed consent" appears to be ideal. The author suggests a distinction between two elements of choice: problem solving and decision making. This distinction helps in identifying appropriate roles for patient and provider, thereby leading to genuine shared decision making.

Physicians in health care management: 7. The patient-physician partnership: changing roles and the desire for information.

Historical views of the patient-physician relationship assumed that the physician's role was to act in the best interests of the patient and to direct care and make decisions about treatment on the patient's behalf. However, under current legal and ethical principles, beneficence is no longer sufficient; respect for autonomy is paramount, necessitating patient participation. None the less, physicians question whether patient participation is realistic in actual clinical situations. This first of two articles reviews models of the patient-physician relationship and the literature about barriers to participation, the effect of participation on patient outcome and the extent to which patients want to be informed. The image of a dependent patient who prefers to be sheltered from harsh truths is not supported. It appears that most patients wish to have information, although there is an identifiable proportion who do not. To be understood, health information must be presented in a way that is appropriate to the patient. Format, content and timing of the material are all important. Mechanisms for incorporating such information into busy clinical practices are crucial.

Managing health services organizations with an educational mission: the case of Canada.

Teaching hospitals represent a major segment of the Canadian health system, accounting for a disproportionate number of beds, patient days, and separations. Thus, although only six percent of hospitals are classified as teaching hospitals, they are responsible for about 36 percent of total hospital operating expenses. While affiliation with a medical school presents unique opportunities for the teaching hospital and increases its prestige, there are clear costs associated with affiliation. Administrators have less control over resource allocation decisions, including the types of teaching programs offered. Teaching hospitals cannot unilaterally design their own teaching programs around specialties and subspecialties of their own choosing; decisions related to teaching programs have a direct impact on the services provided by the hospital and may negatively affect the hospital's ability to fulfill its patient care mission. As education budgets are constrained, teaching hospitals are expected to assume outstanding teaching-related expenses. Teaching hospitals are also expected to shift some of their teaching to alternative settings, such as the community. Thus, teaching hospital administrators will require a strong background in finance as well as negotiation and political skills.

The merger that wasn't: lessons for senior administrators.

A turbulent health care environment has prompted some hospitals to consider integrating services and in some cases merge entirely. Fundamental lessons may be learned by studying how an attempted merger between Women's College Hospital and The Toronto Hospital in Toronto failed--despite board and senior executive support. Clarity of purpose, involvement of essential external and internal stakeholders, rational analysis, ideological fit and political expediency are a few key elements to consider. Once initiated, changes of this magnitude may take on a life of their own with often unpredictable results.

Canadian Medicare: can it work in the United States? Will it survive in Canada?

Any discussion of health care reform in the United States inevitably draws comparisons from the Canadian model. This Article frames the debate over the merits of the Canadian system by introducing its basic features, exploring its advantages, and discussing its limitations. In evaluating the prospects for a Canadian-type system in the United States, the author focuses on the need to rethink--as Canada has--the viability of market-based approaches to health care.

From equal access to health care to equitable access to health: a review of Canadian provincial health commissions and reports.

Having achieved equality of access to health care, Canadian policymakers are setting new policy goals, within resource constraints, primarily to achieve equity of access to health. Across the country, provincial royal commissions have explored a number of policy options to achieve this goal. These options are reviewed and critically analyzed within the context of such challenges in health policy as insufficient access to high-technology care and the limits of medical care, and such external challenges as economic and demographic trends, federal-provincial disputes, and ideological beliefs. Particular attention is given to the implications of a broader definition of health and the concept of regional health authorities. Based on the provincial reviews, the authors conclude that Canada wants to achieve equitable access to health. With the shift of health policy away from the formerly protected arena of medical care, achieving equitable access to health will require both an alteration of priorities and values and considerable political will. Canada will be forced to meet these new challenges to maintain current achievements and to make its system even more successful.

Translating technology assessment into policy. Conceptual issues and tough choices.

Conceptual issues arise in translating the results of technology assessment into policy. A 3 x 3 typology suggests that tough decisions occur when interventions promise increased benefit for increased cost or less benefit for less cost. These decisions are value based; technology assessment alone cannot determine who should receive an intervention and under what circumstances.

Innovative revenue generation.

Innovative revenue generation by Canadian hospitals is drawing increasing attention. After a critical examination of the literature, we classified these into six areas: clinical/diagnostic insured services, clinical/diagnostic non-insured services, hotel services, retail services, administrative services and financial activities. We concluded that many Canadian hospitals are engaging in innovative revenue generation activities, the success of such activities has been mixed, there are many factors to consider when selecting revenue generation activities, many aspects of innovative revenue generation involve sophisticated business and risk management skills not traditionally required in hospital management, and implementation of many such activities requires support from the hospital board, hospital staff and medical staff.

Overconfidence among physicians and nurses: the 'micro-certainty, macro-uncertainty' phenomenon.

Overconfidence in clinicians was examined in two independently designed studies, each using a different research approach. The first study examined treatment choices of physicians in treating breast cancer, and the second rapid decision making among nurses working in Intensive Care Units. In both studies, individual respondents were highly confident they had made the right choice ('micro-certainty'), although there was no consensus across respondents as to what the optimal treatment would be ('macro-uncertainty'). The difference between micro-certainty of individuals and macro-uncertainty within the clinical community may cast some light on the persistence of practice variation. The implications of overconfidence in clinical treatment for patients, practitioners, and professional regulation are discussed.

Health care in Canada: current trends and issues.

Canada's universal health care system is perceived as threatened by rising costs, an aging population, and technological growth. This popular and successful program has largely kept costs under control while maintaining quality and ensuring equity. However, its success demonstrates the limits of medical care; remaining health problems are less amenable to improvement by merely improving access to traditional services. A widening view of health implies a larger health role in other policy arenas, and a larger group of legitimate participants; coordinating an evolving and expanding system becomes increasingly difficult. Policy options include some combination of laissez faire, business as usual, managed care, manpower regulation, and system change. Change implies controversy and conflict. Hard decisions are clearly ahead.