Raisa B. Deber

Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations.

Background  What role do people want to play in treatment decision‐making (DM)?

How does trust affect patient preferences for participation in decision-making?

Objective  Does trust in physicians aid or hinder patient autonomy? We examine the relationship between trust in the recipients doctor, and desire for a participative role in decisions about medical treatment.

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 ischemic heart disease amenable to elective revascularization and ongoing medical therapy.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.

Counting Backward to Health Care's Future: Using Time-to-Death Modeling to Identify Changes in End-of-Life Morbidity and the Impact of Aging on Health Care Expenditures

In most developed countries, as the largest population cohorts approach the age of sixty-five, the impact of population aging on health care expenditures has become a topic of growing interest. This articles examines trends in elderly disability and end-of-life morbidity, estimations of the cost of dying, and models of expenditures as a function of both age and time-to-death and finds broad improvement in mortality and morbidity among the elderly in the developed world. Reduced mortality and low growth in the costs associated with dying could reduce forecasted expenditures, but high growth in expenditures for those not close to death and for nonhospital services could create new economic pressures on health care systems.

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.

Using explicit decision rules to manage issues of justice, risk, and ethics in decision analysis: when is it not rational to maximize expected utility?

Concepts of justice, risk, and ethics can be merged with decision analysis by requiring the analyst to specify explicitly a decision rule or sequence of rules. Decision rules are categorized by whether they consider: 1) aspects of outcome distributions beyond central tendencies; 2) probabilities as well as utilities of outcomes; and 3) means as well as ends. This formulation suggests that distribution-based decision rules could address both risk (for an individual) and justice (for the population). Rational choice under risk if choices are one-time only (vs. repeated events) or if one branch contains unlikely but disastrous outcomes might ignore probability information. Incorporating risk attitude into decision rules rather than utilities could facilitate use of multiattribute approaches to measuring outcomes. Certain ethical concerns could be addressed by prior specification of rules for allowing particular branches. Examples, including selection of polio vaccine strategies, are discussed, and theoretical and practical implications of a decision rule approach noted. Key words: decision making; utility theory; decision analysis; ethics; risk; justice. (Med Decis Making 1990;10:181-194)

Patient, consumer, client, or customer: what do people want to be called?

Objective  To clarify preferred labels for people receiving health care.

The evolving role of health care aides in the long-term care and home and community care sectors in Canada.

Health Care Aides (HCAs) provide up to 80% of the direct care to older Canadians living in long term care facilities, or in their homes. They are an understudied workforce, and calls for health human resources strategies relating to these workers are, we feel, precipitous. First, we need a better understanding of the nature and scope of their work, and of the factors that shape it. Here, we discuss the evolving role of HCAs and the factors that impact how and where they work. The work of HCAs includes role-required behaviors, an increasing array of delegated acts, and extra-role behaviors like emotional support. Role boundaries, particularly instances where some workers over-invest in care beyond expected levels, are identified as one of the biggest concerns among employers of HCAs in the current cost-containment environment. A number of factors significantly impact what these workers do and where they work, including market-level differences, job mobility, and work structure. In Canada, entry into this ‘profession’ is increasingly constrained to the Home and Community Care sector, while market-level and work structure differences constrain job mobility to transitions of only the most experienced workers, to the long-term care sector. We note that this is in direct opposition to recent policy initiatives designed to encourage aging at home. Work structure influences what these workers do, and how they work; many HCAs work for three or four different agencies in order to sustain themselves and their families. Expectations with regard to HCA preparation have changed over the past decade in Canada, and training is emerging as a high priority health human resource issue. An increasing emphasis on improving quality of care and measuring performance, and on integrated team-based care delivery, has considerable implications for worker training. New models of care delivery foreshadow a need for management and leadership expertise - these workers have not historically been prepared for leadership roles. We conclude with a brief discussion of the next steps necessary to generating evidence necessary to informing a health human resource strategy relating to the provision of care to older Canadians.

The intensive care unit work environment: Current challenges and recommendations for the future

Abstract The need for critical care services has grown substantially in the last decade in most of the G8 nations. This increasing demand has accentuated an already existing shortage of trained critical care professionals. Recent studies argue that difficulty in recruiting an appropriate workforce relates to a shortage of graduating professionals and unhealthy work environments in which critical care professionals must work. Objective This narrative review summarizes existing literature and experiences about the key work environment challenges reported within the critical care context and suggests best practices—implemented in hospitals or suggested by professional associations—which can be an initial step in enhancing patient care and professional recruitment and retention in our intensive care units, with particular emphasis on the recruitment and retention of an appropriately trained and satisfied workforce. The experiences are categorized for the physical, emotional, and professional environments. A case study is appended to enhance understanding of the magnitude and some of the proposed remedies of these experiences.

Policy, Payment, and Participation: Long-Term Care Reform in Ontario

Although Canadian Medicare gives the population “reasonable” access” to all “medically necessary” physician and hospital services, long-term care is not formally subject to those conditions. In Ontario, long-term care involves a “patchwork quilt” of government, charitable, for-profit, and personally-provided services; an ongoing consultation has been under way in an attempt to rationalize service financing and provision. This paper reviews the series of policy proposals and the accompanying public consultation processes. It concludes that the emphasis on “community involvement” without a clear definition of “community” or the goals of participation has paradoxically increased the “scope of conflict,” increased frustration among stakeholders, and made policy action more difficult.