Статті в журналах: "American Medical Association. Physicians' Placement Service"

1

Craig, Elise, Erica Brotzman, Benjamin Farthing, Rachel Giesey, and Jenifer Lloyd. "Poor match rates of osteopathic applicants into ACGME dermatology and other competitive specialties." Journal of Osteopathic Medicine 121, no. 3 (February 12, 2021): 281–86. http://dx.doi.org/10.1515/jom-2020-0202.

Повний текст джерела

Анотація:

Abstract Context There has been a steady increase in the number of osteopathic (DO) medical students in the United States without a corresponding increase in DO representation in competitive specialties. Objectives To investigate the trends and impact of the Accreditation Council for Graduate Medical Education (ACGME) single accreditation system on DO match rates into dermatology and other competitive specialty programs. Methods Information was collected through public databases (Electronic Residency Application Service [ERAS]; National Resident Matching Program [NRMP]; Association of American Medical Colleges [AAMC]; National Match Service, Inc. [NMS]; and the ACGME) to evaluate the match statistics of competitive specialties, including dermatology, otolaryngology, orthopedic surgery, neurosurgery, and plastic surgery. Residency program and medical school websites and residency communications were used to confirm whether the match placements were to programs that had traditionally been ACGME-accredited or former American Osteopathic Association (AOA) programs. Results From 2012 to 2016 (pre-unification), osteopathic graduates comprised only 0.5% of the matches the specific specialties studied here and only 0.9% of ACGME dermatology positions. Post-unification (2017–2019), DOs comprised 2.0% of the matches into these specialties and 4.4% of the total ACGME dermatology positions. This apparent increase is misleading, as it is solely due to the transition of formerly AOA programs to ACGME status. The true post-unification DO match rate to traditionally ACGME programs is actually 0.6% for all competitive specialties and 0.4% for dermatology. Post-unification, 27.6% of formerly AOA positions in these competitive specialties were filled by allopathic (MD) applicants. Conclusions DO match rates into dermatology and other competitive specialties were poor prior to GME unification and continue to remain low. This situation, when coupled with the closing of many AOA programs and MDs matching into former AOA positions, threatens the future of osteopathic physicians in competitive specialties. Osteopathic recognition is one way to potentially help preserve osteopathic representation and philosophy in the single accreditation system era. Programs should not be hesitant to consider osteopathic applicants for competitive specialties.

Стилі APA, Harvard, Vancouver, ISO та ін.

2

&NA;. "American Association of Electrodiagnostic Placement Service." Journal of Clinical Neurophysiology 16, no. 5 (September 1999): 498. http://dx.doi.org/10.1097/00004691-199909000-00012.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

3

&NA;. "American Association of Electrodiagnostic Placement Service." Journal of Clinical Neurophysiology 16, no. 6 (November 1999): 576. http://dx.doi.org/10.1097/00004691-199911000-00011.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

4

&NA;. "American Association of Electrodiagnostic Placement Service." Journal of Clinical Neurophysiology 17, no. 1 (January 2000): 110. http://dx.doi.org/10.1097/00004691-200001000-00012.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

5

&NA;. "American Association of Electrodiagnostic Medicine Placement Service." Journal of Clinical Neurophysiology 11, no. 6 (November 1994): 608. http://dx.doi.org/10.1097/00004691-199411000-00009.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

6

Hudson, Kimberly M., Gail Feinberg, Laura Hempstead, Christopher Zipp, John R. Gimpel, and Yi Wang. "Association Between Performance on COMLEX-USA and the American College of Osteopathic Family Physicians In-Service Examination." Journal of Graduate Medical Education 10, no. 5 (October 1, 2018): 543–47. http://dx.doi.org/10.4300/jgme-d-17-00997.1.

Повний текст джерела

Анотація:

ABSTRACT Background The primary goal of residency programs is to select and educate qualified candidates to become competent physicians. Program directors often use performance on licensure examinations to evaluate the ability of candidates during the resident application process. The American College of Osteopathic Family Physicians (ACOFP) administers an in-service examination (ISE) to residents annually. There are few prior studies of the relationship between the Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMLEX-USA) series and formative assessments of residents in training. Objective We explored the relationship between performance on COMLEX-USA and the ACOFP in-service examination to offer support on the use of licensing examinations in resident selection. Methods In 2016, performance data from the COMLEX-USA and the ISE were matched for 3 resident cohorts (2011–2013, inclusive; N = 1384). Correlations were calculated to examine the relationship between COMLEX-USA and ISE scores. Multiple linear regression models were used to determine if performance on COMLEX-USA significantly predicted third-year ISE (ISE-3) scores. Results Findings indicated that correlations among performance on COMLEX-USA and ISE were statistically significant (all P < .001), and there was strong intercorrelation between COMLEX-USA Level 3 and ISE-1 performance (r = 0.57, P < .001). Performance on the COMLEX-USA Levels 1 and 2–Cognitive Examination significantly predicted performance on the ISE-3 (F(2,1381) = 228.8, P < .001). Conclusions The results support using COMLEX-USA as a part of resident selection in family medicine. Additionally, program directors may use performance on COMLEX-USA to predict success on the ISE-3.

Стилі APA, Harvard, Vancouver, ISO та ін.

7

Baadh, Amanjit S., Stephen Rivoli, Jack Ansell, and Robert E. Graham. "Indications for Inferior Vena Cava (IVC) Filter Placement - Assessing Compliance with Accepted Standards Set by Two Professional Societies." Blood 116, no. 21 (November 19, 2010): 2553. http://dx.doi.org/10.1182/blood.v116.21.2553.2553.

Повний текст джерела

Анотація:

Abstract Abstract 2553 Background: Inferior Vena Cava (IVC) filter placement has increased significantly over the past few decades, due to expanding indications for filter placement. Indications for filter placement vary widely depending on which professional society recommendations are followed. Our objectives were to record the number of IVC filters placed in our medium sized metropolitan teaching hospital, assess the effect of medical specialty on placement and evaluate compliance with accepted standards as set by the American College of Chest Physicians (ACCP) and the Society of Interventional Radiology (SIR). Methods: Single-center, retrospective medical record review of all patients who received an IVC filter over 26 months (01/30/2008 - 4/5/2010). Inclusion criteria included patients from both sexes, all ages, filter placement within the aforementioned dates and inpatient procedures performed by interventional radiology. A total of 443 IVC filters were placed in our institution over the time period studied. 48.1% (213) of these filters were placed by interventional radiology. Of these, 187 were reviewed with 26 excluded do to incomplete patient records available at the time of review (July 2010). Medical records were reviewed for patient demographics, clinical course, and compliance with accepted guidelines set by the ACCP and SIR. Results: The average age was 75.3 years and 43.9% of the patients were males. 76.2% of patients were on the medical service (internal medicine and its subspecialties) whereas 22.8% were on non medical services. 87.2 % of filters were recommended by medicine and its subspecialties and 12.8% by non medical specialties. 43.3% of filters placed met guidelines established by the ACCP (Table 1). 79.1% of filters placed met SIR guidelines (Table 2). No documentation was available to assess compliance for 20.9% of filters. 46% of filters placed by internal medicine and its subspecialties met ACCP criteria whereas only 25% of filters recommended by non medicine specialties were compliant with criteria (p value=0.039, 95% CI). Physicians within internal medicine and its subspecialties were compliant with SIR guidelines for 84% of the filters placed, whereas only 46% of non medicine physicians met these indications (p=0.001, 95% CI). 35.8% of filters placed met SIR criteria but did not meet ACCP guidelines. Conclusions: Indications for IVC filter placement varied significantly in this study, less than half of filters placed met ACCP guidelines, yet over three-fourths met criteria set by the SIR, especially when comparing medicine and non medicine specialties. In analyzing the filters which meet indications set by SIR but not ACCP it becomes apparent that most of these are placed for patients classified as “fall risks”, failures of anticoagulation, limited cardiopulmonary reserve and medication noncompliance. Further research needs to be guided towards evaluating if these indications truly merit the placement of an IVC filter. This study strongly suggests a need for harmonization of current guidelines espoused by professional societies. A limitation of our study was that 230 filters placed by vascular surgery and interventional cardiology were not reviewed. Disclosures: No relevant conflicts of interest to declare.

Стилі APA, Harvard, Vancouver, ISO та ін.

8

Laios, Konstantinos. "Professor William Wayne Babcock (1872-1963) and His Innovations in Surgery." Surgical Innovation 25, no. 5 (June 18, 2018): 536–37. http://dx.doi.org/10.1177/1553350618781618.

Повний текст джерела

Анотація:

Professor William Wayne Babcock (1872-1963) is considered as a leading figure of American surgery during early 20th century. He introduced many innovative surgical techniques such as Babcock operation for the treatment of varicose veins, the Babcock-Bacon operation for the treatment of cancer of the rectum and sigmoid colon preserving anal sphincters, the “soup bone” cranioplasty technique, and the nerve disassociation technique for the relief of certain forms of paralysis or parasthesia due to injury or inflammation. He invented many surgical instruments such as Babcock forceps, which is widely used in everyday surgical practice, the Babcock probe, and also sump drain and lamp chimney sump drain, which also bear his name. In 1947, he received the Master Surgeon Award from the International College of Physicians and Surgeons and in 1954 the American Medical Association presented him with the Distinguished Service Medal.

Стилі APA, Harvard, Vancouver, ISO та ін.

9

Hofmeister, Sabrina, Thomas R. O'Neill, and Dennis J. Butler. "Comparative Analysis of the American Board of Family Medicine and American College of Osteopathic Family Physicians In-Training Examinations." Family Medicine 50, no. 10 (November 2, 2018): 746–50. http://dx.doi.org/10.22454/fammed.2018.205747.

Повний текст джерела

Анотація:

Background and Objectives: Family medicine residency programs accredited by the Accreditation Council for Graduate Medical Education and the American Osteopathic Association typically require their residents to take the American Board of Family Medicine’s In-Training Examination (ITE) and the American College of Osteopathic Family Physicians’ In-Service Examination (ISE). With implementation of the single accreditation system (SAS), is it necessary to administer both examinations? This pilot study assessed whether the degree of similarity for the construct of family medicine knowledge and clinical decision making as measured by both exams is high enough to be considered equivalent and analyzed resident ability distribution on both exams. Methods: A repeated measures design was used to determine how similar and how different the rankings of PGY-3s were with regard to their knowledge of family medicine as measured by the ISE and ITE. Eighteen third-year osteopathic residents participated in the analysis, and the response rate was 100%. Results: The correlation between ISE and ITE rankings was moderately high and significantly different from zero (rs=.76, P<0.05). A Wilcoxon signed rank test indicated that the median ISE score of 62 was not statistically significantly different than the median ITE score of 71 (Z=-0.74, P=0.46, 2-tailed). Conclusions: The lack of a difference on statistical analysis of ISE scores and the ITE scores of the PGY-3 residents suggests that the cohort of osteopathic residents in family residency programs and the cohort of residents in ACGME-accredited programs seem to be of comparable ability, therefore there is no clear justification for administering both examinations.

Стилі APA, Harvard, Vancouver, ISO та ін.

10

Lamont, Elizabeth B., Yulei He, S. V. Subramanian, and Alan M. Zaslavsky. "Do Socially Deprived Urban Areas Have Lesser Supplies of Cancer Care Services?" Journal of Clinical Oncology 30, no. 26 (September 10, 2012): 3250–57. http://dx.doi.org/10.1200/jco.2011.40.4228.

Повний текст джерела

Анотація:

Purpose Area social deprivation is associated with unfavorable health outcomes of residents across the full clinical course of cancer from the stage at diagnosis through survival. We sought to determine whether area social factors are associated with the area health care supply. Patients and Methods We studied the area supply of health services required for the provision of guideline-recommended care for patients with breast cancer and colorectal cancer (CRC) in each of the following three distinct clinical domains: screening, treatment, and post-treatment surveillance. We characterized area social factors in 3,096 urban zip code tabulation areas by using Census Bureau data and the health care supply in the corresponding 465 hospital service areas by using American Hospital Association, American Medical Association, and US Food and Drug Administration data. In two-level hierarchical models, we assessed associations between social factors and the supply of health services across areas. Results We found no clear associations between area social factors and the supply of health services essential to the provision of guideline recommended breast cancer and CRC care in urban areas. The measures of health service included the supply of physicians who facilitate screening, treatment, and post-treatment care and the supply of facilities required for the same services. Conclusion Because we found that the supply of types of health care required for the provision of guideline-recommended cancer care for patients with breast cancer and CRC did not vary with markers of area socioeconomic disadvantage, it is possible that previously reported unfavorable breast cancer and CRC outcomes among individuals living in impoverished areas may have occurred despite an apparent adequate area health care supply.

Стилі APA, Harvard, Vancouver, ISO та ін.

11

Dickinson, Timothy, Jeffrey Riley, Ana Steg, and Paul Zabetakis. "Observations from a National Multiple Institution Autotransfusion (ATS) Quality Indicator Program." Journal of ExtraCorporeal Technology 36, no. 2 (June 2004): 153–57. http://dx.doi.org/10.1051/ject/2004362153.

Повний текст джерела

Анотація:

A process to collect universal, mandatory autotransfusion (ATS) procedure quality indicators to measure and monitor ATS quality improvement was designed and implemented by Fresenius Medical Care Extracorporeal Alliance (FMCEA) an outsource provider of extracorporeal services. The indicator program collected and evaluated data that reflect real-world extracorporeal clinical practices and outcomes. The indicator reports provide our clinicians, client physicians, and partner institutions with confidential reports that allow comparison of their practice to evidenced-based performance standards. All ATS procedures reviewed were performed on non-open-heart surgery procedures (on pump or off pump), including vascular, thoracic, orthopedic, and general surgery. After continuous collection and analysis of the indicator data, a hospital is given a report with three components: 1) data analysis that reports summary results and benchmarks the hospital against the other reporting hospitals, 2) corrective action plan that allows the clinical manager to document their investigations and outline plans for continuous quality improvement; and 3) raw data tabulation that allows the clinical manager to identify individual cases that are outliers from the target goal to facilitate local chart reviews. This communication describes FMCEA’s ATS Quality Indicator Program and presents the collective results for the first 13 months (January 2002–January 2003) of data collection. Physicians and ATS service client hospitals value the Quality Indicator Process Reports. ATS service managers use the reports and the subsequent process improvement to meet AaBB (American Association of Blood Banks) and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) standards and guidelines for providing safe patient-care services.

Стилі APA, Harvard, Vancouver, ISO та ін.

12

Carlson, Jestin N., Brian P. Suffoletto, David D. Salcido, Eric S. Logue, and James J. Menegazzi. "Chest compressions do not disrupt the seal created by the laryngeal mask airway during positive pressure ventilation: a preliminary porcine study." CJEM 16, no. 05 (September 2014): 378–82. http://dx.doi.org/10.2310/8000.2014.141029.

Повний текст джерела

Анотація:

ABSTRACT Objective: Pulmonary aspiration of gastric contents occurs 20 to 30% of the time during cardiopulmonary resuscitation (CPR) of cardiac arrest due to loss of protective airway reflexes, pressure changes generated during CPR, and positive pressure ventilation (PPV). Although the American Heart Association has recommended the laryngeal mask airway (LMA) as an acceptable alternative airway for use by emergency medical service personnel, concerns over the capacity of the device to protect from pulmonary aspiration remain.We sought to determine the occurrence of aspiration after LMA placement, CPR, and PPV. Methods: We inserted a size 4 LMA, modified so that a vacuum catheter could be advanced past the LMA diaphragm, into the hypopharynx of 16 consecutive postexperimental mixed-breed domestic swine. Fifteen millilitres of heparinized blood was instilled into the oropharynx. Chest compressions were performed for 60 seconds with asynchronous ventilation via a mechanical ventilator. We then suctioned through the LMA for 1 minute. The catheter was removed and inspected for signs of blood. The LMA cuff was deflated, removed, and inspected for signs of blood. Results: None of 16 animals (95% CI 0-17%) had a positive test for the presence of blood in both the vacuum catheter and the intima of the LMA diaphragm. Conclusions: In this swine model of regurgitation after LMA placement, there were no cases with evidence of blood beyond the seal created by the LMA cuff. Future studies are needed to determine the frequency of pulmonary aspiration after LMA placement during CPR and PPV in the clinical setting.

Стилі APA, Harvard, Vancouver, ISO та ін.

13

Strasser, Julia, Ellen Schenk, Qian Luo, Mandar Bodas, Olivia Anderson, and Candice Chen. "Training in Residency and Provision of Reproductive Health Services Among Family Medicine Physicians." JAMA Network Open 6, no. 8 (August 23, 2023): e2330489. http://dx.doi.org/10.1001/jamanetworkopen.2023.30489.

Повний текст джерела

Анотація:

ImportanceContraception and abortion services are essential health care, and family medicine (FM) physicians are an important part of the workforce providing this care. Residency could inform the reproductive health services FM physicians provide.ObjectiveTo determine which residency training factors are associated with FM physicians’ provision of reproductive health services to Medicaid beneficiaries.Design, Setting, and ParticipantsThis cross-sectional, population-based observational study of inpatient and outpatient FM physicians who completed residency between 2008 and 2018 and treated at least 1 Medicaid beneficiary in 2019 was conducted from November 2022 to March 2023. The study used 2019 American Medical Association Masterfile and Historical Residency file, as well as the 2019 Transformed Medicaid Statistical Information System claims.ExposuresResidency training in community-based or reproductive health-focused programs.Main Outcomes and MeasuresThe outcomes were providing the following to at least 1 Medicaid beneficiary in 2019: prescription contraception (pill, patch, and/or ring), intrauterine device (IUD) and/or contraceptive implant, and dilation and curettage (D&amp;C). Odds of providing each outcome were measured using correlated random-effects regression models adjusted for physician, residency program, and county characteristics.ResultsIn the sample of 21 904 FM physician graduates from 410 FM residency programs, 12 307 were female (56.3%). More than half prescribed contraception to Medicaid beneficiaries (13 373 physicians [61.1%]), with lower proportions providing IUD or implant (4059 physicians [18.5%]) and D&amp;C (152 physicians [.7%]). FM physicians who graduated from a Reproductive Health Education in Family Medicine program, which fully integrates family planning into residency training, had significantly greater odds of providing prescription contraception (odds ratio [OR], 1.23; 95% CI, 1.07-1.42), IUD or implant (OR, 1.79; 95% CI, 1.28-2.48), and D&amp;C (OR, 3.61; 95% CI, 2.02-6.44). Physicians who completed residency at a Teaching Health Center, which emphasizes community-based care, had higher odds of providing an IUD or implant (OR, 1.51; 95% CI, 1.19-1.91).Conclusions and RelevanceIn this cross-sectional study of FM physicians providing Medicaid service, characteristics of residency training including community-based care and integration of family planning training are associated with greater odds of providing reproductive health services. With growing reproductive health policy restrictions, providing adequate training in reproductive health is critical to maintaining access to care, especially for underserved populations.

Стилі APA, Harvard, Vancouver, ISO та ін.

14

Rajasekhar, Anita, Hany Elmariah, Darwin Ang, Lawrence Lottenberg, Rebecca Beyth, and Richard Lottenberg. "Inferior Vena Cava Filters in Trauma Patients: A National Practice Pattern Survey of U.S. Trauma Centers." Blood 120, no. 21 (November 16, 2012): 4249. http://dx.doi.org/10.1182/blood.v120.21.4249.4249.

Повний текст джерела

Анотація:

Abstract Abstract 4249 Background: Despite the paucity of randomized controlled trials and strong observational studies supporting the efficacy of inferior vena cava filters (IVCFs) in venous thromboembolism (VTE) prevention, indications for placement of IVCFs have increased. Further, evidence-based guidelines for removal of retrievable filters do not exist. The purpose of this study was to characterize contemporary IVCF practices in the prevention and management of VTE, and clarify the stakeholders in IVCF placement and retrieval among trauma centers across the United States. Methods: In September 2011 a web-based survey was distributed to 1206 members of the Eastern Association for the Surgery of Trauma (EAST) in 3 waves over 3 weeks. This 31-question multiple choice and open-ended survey addressed: 1) provider and practice characteristics, 2) trauma patient population, 3) clinical practice of IVCF placement and retrieval, and 4) pharmacologic prophylaxis (PP). Results: Of the 1059 eligible providers that care for trauma patients on a routine basis, 281 completed the survey (27% response rate); 27% were identified as trauma directors. Seventy-two percent of all responents practiced in an academic setting and 74.7% in a level-1 trauma center. Sixty percent of trauma directors reported more than 1,000 trauma admissions per year. Familiarity with the 2002 EAST and 2008 American College of Chest Physicians guidelines for IVCF placement was noted by 84.3% and 63.0% of respondents, respectively. The majority of trauma centers placed IVCFs (98.9%), of which 3.6% placed only permanent IVCFs, 27.3% only retrievable IVCFs, and 67.3% both. Only 28.4% of centers had an institutional clinical protocol for IVCF placement and 25.5% for removal of IVCFs. The most common indication for IVCF placement was acute VTE and contraindication to therapeutic anticoagulation (32.4%). Prophylactic IVCFs (pIVCFs) in high-risk patients without known VTE were utilized by 97.6% of respondents. Indications for pIVCFs included inability to receive PP (26.5%), incomplete spinal cord injury (19.8%), and complex pelvic fracture with long bone fracture (19.6%). Filter insertion was performed by interventional radiologists (48.1%), vascular surgeons (35.6%), and/or trauma surgeons (15.5%) at each institution. Ultrasound guidance was used in 23.3% of IVCFs placed and 14.0% of insertions occured at the bedside. Acute and long-term complications encountered by providers included filter migration (21.0%), recurrent VTE (15.5%), hematoma (15.5%), and inferior vena cava thrombosis (13.8%). Surveillance for lower extremity deep vein thromboses in trauma patients was performed by 52% of centers. A registry to track patients with IVCFs was maintained by 38% of centers. Decisions to refer patients for IVCF removal were made by the proceduralist service (37.7%), ordering service (38.7%), and/or service following patients after discharge (12.7%). Only 2.5% of respondents removed IVCFs prior to hospital discharge. Screening for VTE prior to IVCF removal was performed with ultrasound (28%), venogram (14.4%), or computed tomography (2.5%), however 43.3% were uncertain of the screening method. In addition to IVCFs, adjunctive VTE prophylaxis indicated by respondents were sequential compression devices (26.7%), low molecular weight heparin (39.0%), unfractionated heparin (25.2%), fondaparinux (5.4%), or aspirin (2.0%). Only 1% of respondents indicated not using PP in trauma patients with IVCFs. Formal institutional PP guidelines existed in 92.9% of institutions. The most common reasons for contraindication to PP included pelvic or retroperitoneal hematoma requiring transfusion of blood products (20.0%), traumatic brain injury (18.3%), ocular injury with hemorrhage (16.3%), coagulopathy (13.6%), and solid intra-abdominal organ injury (11.4%). Sixty-one providers (7.1%) did not indicate any absolute contraindications for PP outside of acute phase of the above injuries. Conclusion: This study confirms the widespread use of IVCFs for both acute VTE and prophylactic indications. However, considerable variation in practice patterns with regards to institutional protocols for IVCF placement and retireval as well as utilization of adjunctive pharmacologic prophylaxis exists. These differences highlight the need for well-designed randomized controlled trials to address the efficacy and safety of IVCFs in trauma patients. Disclosures: No relevant conflicts of interest to declare.

Стилі APA, Harvard, Vancouver, ISO та ін.

15

Thomas, Matthew. "The Information Rx program Requires More Promotion, More Support and Some Adjustment." Evidence Based Library and Information Practice 5, no. 4 (December 17, 2010): 102. http://dx.doi.org/10.18438/b8xw50.

Повний текст джерела

Анотація:

Objective – To determine the level of awareness of the Information Rx program by Georgia librarians and Georgia American College of Physicians (GACP) members, and the use of Information Rx pads, with which physicians would “prescribe” information for their patients. Design – Descriptive (surveys and interviews). Setting – Georgia, U.S. Surveys were distributed and responded to online. The face-to-face interview locations were not specified. Subjects – One survey, which was provided to the Georgia American College of Physicians (GACP) membership including internal medicine physicians and medical students interested in internal medicine, had 46 respondents. The second survey was sent to librarians who were members of the Georgia Public Library Service (GPLS) and the Georgia Health Sciences Library Association (GHSLA). There were 72 public librarians, 14 hospital librarians and 13 academic medical librarians who responded (as well as 6 not specified in the article). A select group of four medical librarians was chosen for more in-depth interviews. The number of surveys sent out was not provided. Methods – Two online surveys, one for physicians and one for librarians, were administered. No information concerning response rate was provided. Face-to-face interviews with four academic medical librarians were conducted. No further information about the interviewing process was provided such as who conducted the interviews, methods used to ensure objectivity or consistency, or where the interviews were conducted. Main Results – Out of 46 GACP survey respondents, only 4 were familiar with the Information Rx program and only 2 of those had used the information Rx pads, neither of whom had referred anyone to a library for further assistance. The two who had not used the pads were either too busy or didn’t understand the program well enough. Of 105 librarian survey respondents, 46 had heard of Information Rx, 37 had received Information Rx promotional materials, and 12 reported helping patrons look for information on MedlinePlus ‘‘prescribed’’ to them by their doctors. Responses to the open-ended interview questions given to the four interviewed librarians were mixed regarding receipt of program materials, negative regarding the effectiveness of the program, and reported no awareness of any patrons having been helped with information “prescriptions.” To improve the program’s success, the author suggested steps such as providing promotional information on the MedlinePlus site, better integration between MedlinePlus and Information Rx, involving librarians somehow in the process as a whole given their ability to help users navigate and understand MedlinePlus, and marketed more to nurses given their front-line responsibilities. Conclusion – Although the program is somewhat useful, Information Rx has not been promoted or supported sufficiently. Information needs to be linked on the MedlinePlus website, clarification of the program and that it is available at no charge should be emphasized. Librarians should be involved and the target audience may need to be changed to include nurses.

Стилі APA, Harvard, Vancouver, ISO та ін.

16

Atallah, Joseph. "Use of Eptifibatide as a Bridge Antiplatelet Agent for Intrathecal Drug Delivery System Placement." Pain Physician 6;15, no. 6;12 (December 14, 2012): 479–83. http://dx.doi.org/10.36076/ppj.2012/15/479.

Повний текст джерела

Анотація:

Use of antiplatelet agents is becoming increasingly common, and their management may require new strategies if neuroaxial techniques are to be employed in patients who will not tolerate discontinuation of antiplatelet therapy. The patient was a 46-year-old man with a past medical history significant for coronary artery disease and who had undergone 14 stents. He developed stent thrombosis (ST) while on clopidogrel. Following the ST, he was subsequently placed on prasugrel. While on prasugrel, the patient presented for an intrathecal drug delivery system (IDDS) trial and placement due to severe peripheral neuropathy unresponsive to several conservative medical treatments. He had previously undergone an unsuccessful spinal cord stimulator trial and received no pain relief. In consultation with his outside cardiologist, the patient received permission to hold his prasugrel for 7 days prior to his intrathecal pump trial. During the trial period’s inpatient hospitalization, the patient developed chest pain. In consultation with the cardiology service in our institution, it was decided antiplatelet therapy should be re-instituted. The patient was bridged to his IDDS placement after the trial with intravenous eptifibatide. The eptifibatide drip was administered 6 hours prior to the IDDS implant. Functional platelet count was checked one hour before the IDDS was placed and the pump was placed without incident. The eptifibatide drip was reinstituted one hour after the IDDS implantation. The patient was observed for 24 hours on the eptifibatide drip, transitioned to his home dose of prasugrel, and discharged home. At outpatient follow-up one week later, the patient demonstrated no neurologic or hemorrhagic complications and was satisfied with the pain control provided by the IDDS. Prasugrel is an irreversible platelet inhibitor, which prevents ADP-induced platelet aggregation by binding the P2Y12 receptor. Patients taking prasugrel will have deficient platelet activity until new platelets have been produced, a span of approximately 7 days. Eptifibatide is an intravenous glycoprotein IIb/IIIa inhibitor with a short half-life of 2½ hours. Inhibition of glycoprotein IIb/IIIa prevents platelet activation and aggregation. The drug effect ceases once it is discontinued and restoration of platelet function is not dependent upon new platelet production. Patients requiring antiplatelet therapy in need of neuroaxial pain management procedures present challenging problems to pain management physicians. Current guidelines from the American Society of Regional Anesthesia have not identified any bridging agent suitable for patients who may not tolerate prolonged withdrawal from their antiplatelet therapy. In this case, eptifibatide was successfully utilized to bridge a patient whose comorbid conditions necessitated continuous antiplatelet therapy without the prolonged washout common to irreversible antiplatelet agents. Key words: Intrathecal drug delivery system, anticoagulation, pain, eptifibatide, antiplatelet agents.

Стилі APA, Harvard, Vancouver, ISO та ін.

17

Lafata, Jennifer Elston, Richard F. Brown, Michael P. Pignone, Scott Ratliff, and Laura Aubree Shay. "Primary care physicians' endorsement of the importance of shared decision making in diverse cancer screening contexts." Journal of Clinical Oncology 34, no. 7_suppl (March 1, 2016): 179. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.179.

Повний текст джерела

Анотація:

179 Background: Despite widespread advocacy, shared decision making (SDM) is not routinely used in office-based cancer screening discussions. We describe primary care physicians’ (PCPs) endorsement of the importance of SDM in different cancer screening contexts. Methods: Between 3/15-5/15 we administered a mailed survey to PCPs randomly selected from the American Medical Association’s Master File. Using 5-point Likert scales, we report PCP’s ratings of the importance of SDM for 11 specific screening scenarios graded by the US Preventive Service Task Force (USPSTF), four specific to not screening elderly patients. Multivariable logistic regression, accounting for repeated observations, was used to estimate the association of physicians’ endorsement of SDM as ‘very important’ with (1) USPSTF grade A [highest endorsement] vs. others, and (2) if scenario pertained to not screening among the elderly. The model controlled for physician age, gender, race, specialty, medical school affiliation, practice size, and PCP’s internal/external motivation for SDM. Results: PCPs were on average 52 years of age, 38% female, and 69% white (N = 288). They were most likely to rate SDM as ‘very important’ for colorectal cancer (CRC) screening in adults aged 50-75 (69%), and least likely for CRC screening in adults aged > 85 (34%). Model results indicated PCPs were significantly (p < 0.01) more likely to endorse SDM as ‘very important’ for A-grade services compared to others, particularly D-grade services (OR = 0.63), and less likely to do so when decision was not to screen among elderly (OR = 0.45). PCPs with more internal motivation for SDM were more likely to endorse its importance (OR = 2.29), but no other physician characteristic was associated with SDM endorsement. Conclusions: The more PCPs internally value SDM, the more likely they are to endorse it as very important regardless of screening scenario. Yet, PCPs’ endorsement varied by USPSTF grade, being particularly low when screening was not recommended, especially when the decision pertained to screening not recommended among elderly patients.

Стилі APA, Harvard, Vancouver, ISO та ін.

18

Manchikanti, Laxmaiah. "Description of Documentation in the Management of Chronic Spinal Pain." Pain Physician 4;12, no. 4;7 (July 14, 2009): E199—E224. http://dx.doi.org/10.36076/ppj.2009/12/e199.

Повний текст джерела

Анотація:

Documentation assists health care professionals in providing appropriate services to patients by documenting indications and medical necessity, and reflects the competency and character of the physician. Documentation is considered a cornerstone of the quality of patient care. This is nowhere more true than in interventional pain management. Thus, documentation in physicians’ offices, hospital settings, ambulatory surgery centers, rehabilitation centers, and other settings must be accurate, complete, and reflect all of the services provided during each encounter. The Centers for Medicare and Medicaid Services (CMS) defines medical necessity in these terms: “no payment may be made under Part A or Part B for any expense incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a participant.” The American Medical Association (AMA) defines medical necessity as, “health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is in accordance with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient, physician, or other health care provider.” Documentation requirements include an appropriate medical record utilizing recognized and acceptable standards of documentation and an established process. However, the evolution of electronic medical records (EMRs) or electronic health records (EHRs) nullifies many of the issues faced in handwritten documentation. Multiple types of documentation include evaluation and management services and documentations in ambulatory surgery centers, hospital outpatient departments, and in office settings, specifically while performing interventional procedures. Evaluation and management services incorporate 5 levels of service for consultations and visits, with multiple key elements of service including history, physical examination, and medical decision making. Documentation of interventional procedures in general requires a history and physical, indication and medical necessity, intra-operative procedural description, post-operative monitoring and ambulation, discharge, and disposition. With minor variations, these requirements are similar for an in-office setting, hospital out patient department, and ambulatory surgery centers. Key words: Documentation, billing, coding, compliance, fraud and abuse, interventional techniques, evaluation and management services, office visit, consultation, new patient, established patient

Стилі APA, Harvard, Vancouver, ISO та ін.

19

Groups, African Pathologists' Summit Working. "Proceedings of the African Pathologists Summit; March 22–23, 2013; Dakar, Senegal: A Summary." Archives of Pathology & Laboratory Medicine 139, no. 1 (June 25, 2014): 126–32. http://dx.doi.org/10.5858/arpa.2013-0732-cc.

Повний текст джерела

Анотація:

Context This report presents the proceedings of the African Pathologists Summit, held under the auspices of the African Organization for Research and Training in Cancer. Objectives To deliberate on the challenges and constraints of the practice of pathology in Sub-Saharan Africa and the avenues for addressing them. Participants Collaborating organizations included the American Society for Clinical Pathology; Association of Pathologists of Nigeria; British Division of the International Academy of Pathology; College of Pathologists of East, Central and Southern Africa; East African Division of the International Academy of Pathology; Friends of Africa–United States and Canadian Academy of Pathology Initiative; International Academy of Pathology; International Network for Cancer Treatment and Research; National Cancer Institute; National Health and Laboratory Service of South Africa; Nigerian Postgraduate Medical College; Royal College of Pathologists; West African Division of the International Academy of Pathology; and Faculty of Laboratory Medicine of the West African College of Physicians. Evidence Information on the status of the practice of pathology was based on the experience of the participants, who are current or past practitioners of pathology or are involved in pathology education and research in Sub-Saharan Africa. Consensus Process The deliberations were carried out through presentations and working discussion groups. Conclusions The significant lack of professional and technical personnel, inadequate infrastructure, limited training opportunities, poor funding of pathology services in Sub-Saharan Africa, and their significant impact on patient care were noted. The urgency of addressing these issues was recognized, and the recommendations that were made are contained in this report.

Стилі APA, Harvard, Vancouver, ISO та ін.

20

Pai, Menaka, Karen A. Moffat, Elizabeth Plumhoff, Dorothy M. Adcock, James L. Zehnder, and Catherine PM Hayward. "Critical Values in the Coagulation Laboratory: Results of a Survey of the North American Specialized Coagulation Laboratory Association." Blood 114, no. 22 (November 20, 2009): 1415. http://dx.doi.org/10.1182/blood.v114.22.1415.1415.

Повний текст джерела

Анотація:

Abstract Abstract 1415 Poster Board I-438 Introduction: Critical laboratory values (CVs) are those that indicate the patient is in danger of death unless corrective action is initiated immediately. CVs are an important feature of laboratory practice parameters, standards of regulatory agencies (including the Joint Commission's National Patient Safety Goals), and national and institutional quality improvement studies. However, there has been no research into CVs in coagulation laboratories. Our objectives were to determine: 1) The current policies on CVs in specialized coagulation laboratories 2) Current patterns of practice for reporting CVs for coagulation parameters; and 3) If there is any consensus, based on practice, on CVs for coagulation tests. Methods: A web-based survey on CVs was distributed to members of the North American Specialized Coagulation Laboratory Association in February 2009. Results: 38 laboratories participated. 97% had CVs for coagulation tests in place. 85% of laboratories used local opinion or consensus to set their CV policies, likely reflecting a lack of published data. 9% of laboratories were unsure where their CVs came from. CV reporting practices were fairly uniform. 97% of surveyed laboratories authorized technologists to report CVs, and only a minority (<40%) involved senior technologists or laboratory physicians in reporting. CV policies at almost all sites (97%) authorized the patient's nurse or MD, or the ordering MD to receive CV results. Medical students, clerical staff, or uninvolved staff nurses were rarely authorized to receive CVs (3%, 13%, and 37%, respectively). Policies in all participating laboratories required documentation of CV communication. Telephone was the primary method of communication, with 39% of sites used electronic broadcast or forced print as an adjunct. Inconsistency was noted in strategies to handle repeat CVs on the same patient, ranging from reporting all CVs, to reporting worsening CVs, to not reporting CVs on certain patient populations (e.g. critical FVIII:C levels in known hemophiliacs). After-hours communication of CVs on outpatients and referred clients was identified as challenging. All sites first attempted to telephone the patient's on-call MD, and if unsuccessful, sent a report by facsimile, contacted the Laboratory Chief of Service, or delayed reporting until the next day. When laboratories were asked about their CV values, over 80% had CVs for the INR (mean > 5, range > 2 - 6), aPTT (mean > 100 sec, range > 45 - 150 sec) and fibrinogen level (mean < 90 mg/dL, range < 50 - 100 mg/dL). Fewer laboratories (< 25%) had CVs for less commonly performed coagulation tests, including anti-Xa levels, factor and inhibitor assays, and thrombophilia testing. These CVs were more heterogeneous. Conclusion: This survey identified several potential areas for improvement in the way specialized coagulation laboratories handle CVs. Consensus data would assist laboratories in standardizing their policies, and establishing benchmarks for CV reporting and policy review. It would also ensure that a laboratory's CVs are in line with those of its peers, and are clinically relevant. The workload associated with CVs for coagulation assays is unknown, and it is possible that some of the current reporting strategies lead to inefficiencies and delays (e.g. reporting CVs for tests that are not truly life threatening; lack of established policies for after-hours handling of CVs when an on-call physician cannot be reached). Our study identifies an important need for further evaluation and standardization of CVs for coagulation tests. Disclosures: No relevant conflicts of interest to declare.

Стилі APA, Harvard, Vancouver, ISO та ін.

21

Al-Kharouf, Khaled Farid Khaled, Faisal Idrees Khan, and Greg AJ Robertson. "Assessing the readability of online information about jones fracture." World Journal of Methodology 13, no. 5 (December 20, 2023): 439–45. http://dx.doi.org/10.5662/wjm.v13.i5.439.

Повний текст джерела

Анотація:

BACKGROUND Hand in hand with technological advancements, treatment modalities continue to grow. With the turn of the century, the internet has become the number one source of information for almost every topic. Thus, many patients look toward the internet as their primary source of information to learn about their respective medical conditions. The American Medical Association and National Institute of Health strongly recommend that online medical information be written at the 6th to 8th-grade level to aid comprehension by patients of all literacy backgrounds. AIM To assess the readability of online information regarding Jones fracture. Our hypothesis is that the reading level of medical information published on websites far exceeds the recommended reading level of 6th-8th grade as proposed by the American Medical Associate and National Institute of Health. The result of this study can help us formulate improved recommendations for publishing more comprehensible material and, thus, eventually improve patient compliance and clinical outcomes. METHODS The exact phrase “Jones fracture” was queried on the three most common search engines, Google, Yahoo!, and Bing, on December 28, 2022. As of December 2022, Google held 84%, Bing held 9%, and Yahoo! held 2% of the worldwide search engine market share. Web pages uniform resource locator from the first three pages of search results were recorded from each search engine. These web pages were classified according to academic, physician-sponsored, governmental and non-government organizations (NGO), commercial, and unspecified as per formally defined categories. Websites associated with an educational institution or medical organization were classified as academic. Websites with products for sale, corporate sponsorship, or advertisements were classified as commercial. Governmental websites or NGOs comprised those that received government subsidies or grants. Webpages that were independently owned by physicians or physician groups were respectively classed as physician sponsored. The remainder of websites that did not fall under the above categories were classified as unspecified. RESULTS A total of 93 websites were analyzed for reading assessment. A whopping 44% of websites were commercial, followed by 22% of physician-sponsored websites. Third place belonged to non-government organization websites holding a 15% share. The academic website held a meager 9% portion, while unspecified sites were 3%. The table illustrates mean readability scores, along with average cumulative grade level. The average grade level was 10.95 ± 2.28 for all websites, with a range of 6.18 to 18.90. Since P values were more than 0.05, there was not a significant statistical difference between the first page results and the results of all pages. Thus, we can rationalize that readability scores are consistent throughout all pages of a website. CONCLUSION Hand in hand with technological advancements, treatment modalities continue to grow. With the turn of the century, the internet has become the number one source of information for almost every topic. Thus, many patients look towards the internet as the primary source of information to learn about their respective medical conditions. Our study demonstrates that current online medical information regarding Jones fracture is written at an extraordinarily high-grade level, with an average grade level of all websites at 10.95, nearly an 10th-grade educational level. The American Medical Association and National Institute of Health strongly recommend that online medical information should be written at the 6th to 8th-grade level to aid comprehension by patients of all literacy backgrounds. On the contrary, most of the medical information evaluated was at an 10th-grade level, which far exceeds recommendations by AMA and NIH. This is particularly relevant because readability scores are directly proportional to the level of comprehension attained by readers, thus directly impacting patient outcomes. In conclusion, we suggest and encourage that all online reading materials should be re-written at the 6th to 8th-grade level in a public service effort to increase compliance with treatment goals and raise awareness of preventive measures.

Стилі APA, Harvard, Vancouver, ISO та ін.

22

Erikson, Clese, Edward Salsberg, Gaetano Forte, Suanna Bruinooge, and Michael Goldstein. "Future Supply and Demand for Oncologists : Challenges to Assuring Access to Oncology Services." Journal of Oncology Practice 3, no. 2 (March 2007): 79–86. http://dx.doi.org/10.1200/jop.0723601.

Повний текст джерела

Анотація:

Purpose To conduct a comprehensive analysis of supply of and demand for oncology services through 2020. This study was commissioned by the Board of Directors of ASCO. Methods New data on physician supply gathered from surveys of practicing oncologists, oncology fellows, and fellowship program directors were analyzed, along with 2005 American Medical Association Masterfile data on practicing medical oncologists, hematologists/oncologists, and gynecologic oncologists, to determine the baseline capacity and to forecast visit capacity through 2020. Demand for visits was calculated by applying age-, sex-, and time-from-diagnosis-visit rate data from the National Cancer Institute's analysis of the 1998 to 2002 Surveillance, Epidemiology and End Results (SEER) database to the National Cancer Institute's cancer incidence and prevalence projections. The cancer incidence and prevalence projections were calculated by applying a 3-year average (2000–2002) of age- and sex-specific cancer rates from SEER to the US Census Bureau population projections released on March 2004. The baseline supply and demand forecasts assume no change in cancer care delivery and physician practice patterns. Alternate scenarios were constructed by changing assumptions in the baseline models. Results Demand for oncology services is expected to rise rapidly, driven by the aging and growth of the population and improvements in cancer survival rates, at the same time the oncology workforce is aging and retiring in increasing numbers. Demand is expected to rise 48% between 2005 and 2020. The supply of services provided by oncologists during this time is expected to grow more slowly, approximately 14%, based on the current age distribution and practice patterns of oncologists and the number of oncology fellowship positions. This translates into a shortage of 9.4 to 15.0 million visits, or 2,550 to 4,080 oncologists—roughly one-quarter to one-third of the 2005 supply. The baseline projections do not include any alterations based on changes in practice patterns, service use, or cancer treatments. Various alternate scenarios were also developed to show how supply and demand might change under different assumptions. Conclusions ASCO, policy makers, and the public have major challenges ahead of them to forestall likely shortages in the capacity to meet future demand for oncology services. A multifaceted strategy will be needed to ensure that Americans have access to oncology services in 2020, as no single action will fill the likely gap between supply and demand. Among the options to consider are increasing the number of oncology fellowship positions, increasing use of nonphysician clinicians, increasing the role of primary care physicians in the care of patients in remission, and redesigning service delivery.

Стилі APA, Harvard, Vancouver, ISO та ін.

23

Singh, Rahul, and Charin Hanlon. ""Seven Is the New Ten" - Comprehensive Quality Improvement Project to Adopt Restrictive Transfusion Strategies in a Community Hospital." Blood 126, no. 23 (December 3, 2015): 5574. http://dx.doi.org/10.1182/blood.v126.23.5574.5574.

Повний текст джерела

Анотація:

Abstract Introduction: An estimated 13,785,000 units of packed red blood cells (PRBC) were transfused in the US in 2011 of which an estimated 57.9% were found to be from the medical service. Risks of blood transfusion include infections and transfusion reactions. In 2012, the American Association of Blood Banks released new guidelines for PRBC transfusion in hospitalized, hemodynamically stable patients. These guidelines set a threshold Hb of ≤7 g/dL in critically-ill patients, and a Hb ≤8 g/dL for surgical patients, for patients with pre-existing cardiovascular disease, or for patients with symptoms (tachycardia, chest pain or hypotension not corrected by crystalloids). Methods: An IRB-approved retrospective study of inpatient PRBC transfusions at New Hanover Regional Medical Center in Wilmington, NC was conducted in 2013. The average pre-treatment Hb was noted to be 7.42 ± 0.92 (p=0.0009) and average number of units transfused were 1.78 ± 0.58 (p=0.1133). The average number of units transfused were =1.5, and 31% of the time 1 unit was given. This data prompted a quality improvement initiative to improve in hospital transfusion strategies. The PDSA cycle included the following interventions: Hospital administration created a "Transfusion Safety Officer." A transfusion committee championed by the Blood Bank Director was formed. In addition, a series of hospital wide didactics centered on restrictive transfusion practices were held, targeting nursing and physicians of all disciplines. A public relations campaign was launched by the hospital involving posters, newsletters, bulletins, and emails centered around slogans "7 is the new 10" and "1 is better than 2." Four months after this, a new computerized physician order set was created by the Transfusion Committee and instituted in September 2014. The order set specifically separated out chronic anemia from acute blood loss anemia. Under the chronic anemia tab, practitioners can select the reason for PRBC transfusion based off of AABB guidelines, but are restricted to only transfusing 1 unit of PRBC at a time. Finally a new "My Report" has been built within EPIC EMR to allow a physician to see their transfusion average Hb and number of units ordered. An IRB-exempt review of PRBC transfusions after the quality improvement impact and post CPOE go-live date was conducted. A total of 493 PRBC transfusions in non-acute blood loss patients were given between 9/11/14-11/1/14. The average pre-treatment Hb 7.0 of which 59% of the time 1 unit was PRBC was ordered. Discussion: A comprehensive, interdisciplinary QI project can successfully reduce unnecessary PRBC transfusions. By applying the PDSA cycle and harnessing the power of the EMR, we can improve the rapidity with which physicians adopt new evidence based guidelines. The success of a hospital-wide QI project of this magnitude hinges on a motivated project management team able to engage all necessary stake-holders, to include the hospital C-Suite. Disclosures No relevant conflicts of interest to declare.

Стилі APA, Harvard, Vancouver, ISO та ін.

24

Singh, Rahul, and Charin Hanlon. "Can “Seven Be The New Ten” - Adoption Of Restrictive Transfusion Strategies In a Community Hospital." Blood 122, no. 21 (November 15, 2013): 2935. http://dx.doi.org/10.1182/blood.v122.21.2935.2935.

Повний текст джерела

Анотація:

Abstract Background An estimated 13,785,000 units of packed red blood cells (PRBC) were transfused in the United States in 2011 of which an estimated 57.9% were found to be from the general medical service, the ICU or hematology/oncology. Risks of blood transfusion include infections, transfusion reactions circulatory overload, and transfusion-related immunomodulation. Furthermore, there is an economic cost to the administration of blood and a personal cost to those volunteers who give their time. There have been a number of guidelines published for the administration of PRBCs. In the past year, the American Association of Blood Banks released new guidelines for PRBC transfusion in hospitalized, hemodynamically stable patients. These guidelines set a threshold Hb of ≤7 g/dL in critically-ill patients, and a Hb ≤8 g/dL for surgical patients, for patients with pre-existing cardiovascular disease, or for patients with relevant symptoms. Symptoms were defined as tachycardia, chest pain or hypotension not corrected by crystalloids. We studied the potential impact on our inpatient hospital utilization of PRBC over time in relation to the publication of recent guidelines. Methods With IRB approval, a retrospective study of PRBC transfusion at New Hanover Regional Medical Center in Wilmington, NC was conducted. The primary endpoint of the study was to evaluate the impact of the new AABB guidelines on the transfusion utilization in the first 12 months. Secondary endpoints included a cost analysis, an evaluation of the use of PRBC for two pre-specified Hb levels, and a quantification of the number of units transfused. A total of 337 patients were reviewed. 116 were excluded due to one of the following reasons: anemia attributed to active blood loss, the presence of stage 5 chronic kidney disease, the presence of an acute coronary syndrome, the recent administration of outpatient transfusions, the use of blood products besides PRBCS, and the timing of a transfusion in the postoperative period. We randomly assigned two separate timeframes to review transfusions at ≤ 4 months and 8-12 months after the AABB guidelines were published. Data was analyzed using Chi-square and T tests. Results The average pre-treatment hemoglobin for the group ≤4 months was 7.82 ± 0.85 and 7.42 ± 0.92 for the 8-12 month group (p=0.0009). The average number of units transfused were 1.66 ± 0.53 and 1.78 ± 0.58 (P=0.1133), respectively. For those patients whose Hb was ≤ 7.0, there was a 21.6% reduction in inappropriate transfusions 8-12 months after the guidelines were released compared with the first 4 months (Chi-Square p = 0.0070). For those patients whose Hb was ≤ 8.0, the number of inappropriate transfusions went from 40.7% in the first group to 17.3% in the second group (Chi-Square p=0.0001). The total cost of transfusions to the patients was estimated to be $102,400 and $55,600 to the hospital. The potential savings if all transfusions were given according to the new guidelines is estimated to be $66,389 to the patients and $36,037 to the hospital. A total of 11,577 transfusions were given between 6/12/12-3/13/13. If the guidelines had been strictly followed, the number of transfusions would have been reduced to 3,855 transfusions. Discussion An improvement in adherence to AABB guidelines with a more restrictive PRBC transfusion strategy was found over time. This can be attributed to physicians practicing evidenced-based medicine. Data of transfusions at pre-treatment Hb ≤7, suggest that physicians are becoming more restrictive in their threshold for transfusions with a statistically significance in the drop of the average pre-treatment hemoglobin. Despite this restrictive pattern, physicians are still uncomfortable at transfusing 1 unit at a time. Although it was not statistically significant between the two groups, the average number of units transfused were ≥1.5, and 67% of the time 2 units were given. Overtransfusion with PRBCs is a problem that needs to be addressed. Physicians should give one unit and reassess for an appropriate response. This strategy will reduce cost to the patient and hospital. We feel that additional improvement is still possible and we are forming a blood management committee to promote better PRBC transfusion practice guidelines. We plan a series of educational presentations to each department along with a new Computerized Physician Order Set to improve patient care and reduce overall cost to the health care system. Disclosures: No relevant conflicts of interest to declare.

Стилі APA, Harvard, Vancouver, ISO та ін.

25

Pless, Ivan B. "Child Health in Canada." Pediatrics 86, no. 6 (December 1, 1990): 1027–32. http://dx.doi.org/10.1542/peds.86.6.1027.

Повний текст джерела

Анотація:

These data, coupled with the description of what is really an elegantly simple system of health services, provide a compelling argument for legislators to consider seriously some form of national health insurance for the US. This seems to be the conclusion of many Americans based on recent polls. Other arguments in support of comprehensive health insurance, at least for children, have been heard from some unusual quarters. Many of those advocating reconsideration of this issue, apart from some politicians, include economists, some branches of `organized medicine,' and even business (The Financial Post. November 3, 1989). For example, Lee Iacocca has written: "We've had a war on health care costs in this country for over 10 years, and we've lost it. Those costs have gone up year after year at almost double the rate of inflation, and they now account for about $550 billion a year or over 11% of our GNP." (Inside Guide. 1989:25) He goes on to call attention to the fact that the per capita health bill in the US is 41% higher than Canada's, 61% higher than Sweden's, 85% higher than France's, 131% more than Japan's, and 171% above Great Britain. As Iaccoca points out, if it was the case that the US was getting more for its investment than the others, the higher prices would make sense. But, he adds, "There is little such evidence. Life expectancy in the US is no better than the rest of the Western world, and infant mortality rates are one of the worst. There are nearly 40 million people without any health insurance coverage." He notes that an appendectomy or hysterectomy costs 3.5 times as much in California as in Ontario, and the ratio of costs is 5 times greater for a coronary artery bypass, and 7 times greater for an electrocardiogram. Iacocca's concern arises in large part because American business pays a large part of the costs of what he views as an `overpriced system.' Those costs go directly into the price of goods, and this amounts to an export tax when those goods are sold abroad. He estimates that over $700 of the cost of producing a car in the US goes to pay for health care for employees, compared with $223 in Canada. Between 1978 and 1980, General Motors reportedly spent three times as much on health insurance as it did on the steel used to manufacture its cars! Apart from these hard core economic issues, other differences are more subtle. Once concerns about paying for conventional medical care are set aside, serious consideration can be given to broader questions related to health and health care. In Canada there now appears to be a rapidly growing acceptance of the view that the main factors responsible for the health of populations are clean water, good food, education, employment, housing and, perhaps, good genes. This view has been articulated by the Population Health Group of the Canadian Institute for Advanced Research. Nonetheless, the view that equitable access to medical care is essential to the integrity of a fair and just society remains firmly entrenched. As a consequence Canadians maintain a firm desire to accept even the high costs associated with elaborate hospital care and physician services to be confident that they will continue to be free for all. Many have observed that the major improvements in the health of most Western societies during the last 200 years predated advances in medical diagnosis and therapy by many years. Accordingly, some experts are convinced that the main determinants of health lie beyond traditional medical care. They note that the persistent discrepancies in the health status of different sectors of the population, particularly those divided by income or social class, may reflect complex social and environmental phenomena. Those in higher social class groups may have been quicker to adopt better lifestyles with respect to matters like smoking and diet. Similarly, social relationships, the control one has over one's own life, security of employment, and a sense of self-worth, all appear to be strongly related to health in the aggregate From this perspective it might appear that the arguments of critics of health insurance have some merit. The opponents suggest that it is not the absence of insurance per se that accounts for the embarrassing differences in health statistics when children in the US are compared with those in other nations, but rather differences in population composition. The argument is made that the American population has more poor, more blacks, and generally more heterogeneity than those of countries being compared. Even if that were true (although each point is debatable, and it seems a strange argument coming from what many consider to be one of the richest nations in the world), even if conceded, it seems to make the case for health insurance all the more compelling. This is so because there can be no doubt that one main effect of such insurance is to narrow the gap in access to and the use of services between the rich and the poor. Hence the more poor a nation has, the stronger the case for health insurance. Successive ministers of Health and Welfare in Canada, beginning with Lalonde in 1974 to Epp in 1987, have emphasized the importance of environment and lifestyle, as opposed to physicians and hospitals in obtaining further improvements in the health of Canadians. A cynic might suggest that these calls are motivated largely by the pressure to control spiralling health care costs, but the evidence appears to suggest that regardless of motive, they are on the right track. Contrary to views propagated in the US during the Reagan era, there is no evidence from Canada's experience that deregulation and competition either improves the public's health or reduces costs. In fact, the Canadian example suggests just the opposite, that the more care is made free to the patient at the time of receipt of service, and the more the system is planned and regulated by the state in the public interest, the better is the quality of service, the better the health of the people, and the less it costs. Despite the evidence, spokespersons for "the loyal opposition" persist: "Universal health insurance is not a good idea. . . [it] would fly in the face of the American way of doing things. . . .The United States is unique, and our pluralistic approach is unique. There is no reason to think that an imported system would be successful here or that American citizens would accept its implicit restrictions. . . . Other countries ignore appropriateness and effectiveness; they ignore the many complex elements of high-quality care that we in America demand; and they largely ignore the citizen's right to free choice, a concept we hold very dear." That dissenting opinion, written, perhaps not surprisingly by James S. Todd, of the American Medical Association, is certainly not one shared by most Canadians. It would seem that many Americans would gladly change places with their Canadian cousins or those of any of the other nations who long ago accepted that universal health insurance is a requisite for national self-respect.

Стилі APA, Harvard, Vancouver, ISO та ін.

26

Tang, Derek, Ankush Taneja, Preety Rajora, and Renu Patel. "Systematic Literature Review of the Economic Burden and Cost of Illness in Patients with Myelofibrosis." Blood 134, Supplement_1 (November 13, 2019): 2184. http://dx.doi.org/10.1182/blood-2019-122919.

Повний текст джерела

Анотація:

Introduction: Myelofibrosis (MF) is a rare bone marrow cancer classified as a myeloproliferative neoplasm in which bone marrow is replaced by fibrous (scar) tissue, impairing the production of normal blood cells. MF has a global incidence of approximately 0.58 new cases per 100,000 person-years, with many patients experiencing short survival (approximately 6 years). Most patients with MF are found to have either intermediate-2 or high-risk MF, as per their prognostic score (International Prognostic Scoring System [IPSS] or Dynamic IPSS). The economic impact of MF has been studied in individual real-world settings, each of which may have limited generalizability; however, the holistic economic burden of MF is not well understood. The objective of this systematic literature review (SLR) was to describe economic evidence for patients with MF including cost and resource use data. Methods: A SLR was conducted in Embase®, MEDLINE®, the National Health Service Economic Evaluation Database (NHS EED), and the American Economic Association (AEA) EconLit® to identify evidence published from database inception to July 2018. Conference proceedings and bibliographies were also searched. Studies were included if they were published in the English language and reported economic burden associated with adult patients with MF. The evidence was not restricted by any country or time limits. Two reviewers assessed each citation against predefined eligibility criteria, with discrepancies reconciled by a third independent reviewer. All the extracted data were quality checked by a second independent reviewer. A descriptive qualitative analysis was conducted to identify the patterns of economic burden in MF across different countries. Results: A total of 771 potentially relevant abstracts were identified and screened, of which 23 studies were included in the final analysis. Eleven studies reported cost data only, 10 studies reported both cost and resource use data, and 2 studies reported on the budget impact of treatment for MF. Eight of the included studies were conducted in the USA, 2 each in the UK, Canada, and Ireland, and the remaining 9 reported data from other countries. Eight of the included studies reported total MF costs, 4 studies reported productivity losses related to employment, and 3 studies reported indirect costs related to productivity and informal care. The remaining studies reported cost-effectiveness data for the treatment of MF. Of the 5 studies that reported categorical costs, 3 reported that outpatient costs were the major driver of costs, followed by inpatient costs. Among the studies conducted in the USA, total medical healthcare costs associated with MF ranged from USD 21,000 to USD 66,000 per patient. Three European studies reported that the annual productivity losses per patient ranged from EUR 7,774 to EUR 11,000, with total annual productivity losses as high as EUR 217,975. Two US studies compared the total MF-related healthcare costs with age- and sex-matched controls; costs were significantly higher in the MF cohort compared with matched controls (P < 0.05), especially for inpatient costs, outpatient costs, and pharmacy costs (Figure). Four studies, with a majority of the MF patients aged > 50 years, reported that 20-60% of the patients were absent from work, with a mean of 6.2 hours of work missed in the past 7 days. Among the hospitalized patients, 3 studies reported that the median length of stay for patients with MF ranged from 2.5 to 6.6 days, with 46% of patients utilizing emergency room visits and services. Conclusions: MF is associated with significant economic burden and work productivity loss to the health system, patients, and their families. Sustained efforts to develop more effective treatments are required in order to reduce the economic burden associated with MF and help patients and physicians improve disease management. Disclosures Tang: Celgene Corporation: Employment, Equity Ownership. Taneja:BresMed Health Solutions Ltd: Employment. Rajora:BresMed Health Solutions Ltd: Employment. Patel:BresMed: Employment.

Стилі APA, Harvard, Vancouver, ISO та ін.

27

Beuran, M. "TRAUMA CARE: HIGHLY DEMANDING, TREMENDOUS BENEFITS." Journal of Surgical Sciences 2, no. 3 (July 1, 2015): 111–14. http://dx.doi.org/10.33695/jss.v2i3.117.

Повний текст джерела

Анотація:

From its beginning, mankind suffered injuries through falling, fire, drowning and human aggression [1]. Although the frequency and the kinetics modifiy over millennia, trauma continues to represent an important cause of morbidity and mortality even in the modern society [1]. Significant progresses in the trauma surgery were due to military conflicts, which next to social sufferance came with important steps in injuries’ management, further applied in civilian hospitals. The foundation of modern trauma systems was started by Dominique Jean Larrey (1766-1842) during the Napoleonic Rin military campaign from 1792. The wounded who remained on the battlefield till the end of the battle to receive medical care, usually more than 24 hours, from that moment were transported during the conflict with flying ambulances to mobile hospitals. Starting with the First World War, through the usage of antiseptics, blood transfusions, and fracture management, the mortality decreased from 39% in the Crimean War (1853–1856) to 10%. One of the most preeminent figures of the Second World War was Michael DeBakey, who created the Mobile Army Surgical Hospitals (MASH), concept very similar to the Larrey’s unit. In 1941, in England, Birmingham Accident Hospital was opened, specially designed for injured people, this being the first trauma center worldwide. During the Golf War (1990–1991) the MASH were used for the last time, being replaced by Forward Surgical Teams, very mobile units satisfying the necessities of the nowadays infantry [1]. Nowadays, trauma meets the pandemic criteria, everyday 16,000 people worldwide are dying, injuries representing one of the first five causes of mortality for all the age groups below 60 [2]. A recent 12-month analysis of trauma pattern in the Emergency Hospital of Bucharest revealed 141 patients, 72.3% males, with a mean age of 43.52 ± 19 years, and a mean New Injury Severity Score (NISS) of 27.58 ± 11.32 [3]. The etiology was traffic related in 101 (71.6%), falls in 28 (19.9%) and crushing in 7 (5%) cases. The overall mortality was as high as 30%, for patients with a mean NISS of 37.63 [3]. At the scene, early recognition of severe injuries and a high index of suspicion according to trauma kinetics may allow a correct triage of patients [4]. A functional trauma system should continuously evaluate the rate of over- and under-triage [5]. The over-triage represents the transfer to a very severe patient to a center without necessary resources, while under-triage means a low injured patient referred to a highly specialized center. If under-triage generates preventable deaths, the over-triage comes with a high financial and personal burden for the already overloaded tertiary centers [5]. To maximize the chance for survival, the major trauma patients should be transported as rapid as possible to a trauma center [6]. The initial resuscitation of trauma patients was divided into two time intervals: ten platinum minutes and golden hour [6]. During the ten platinum minutes the airways should be managed, the exsanguinating bleeding should be stopped, and the critical patients should be transported from the scene. During the golden hour all the life-threatening lesions should be addressed, but unfortunately many patients spend this time in the prehospital setting [6]. These time intervals came from Trunkey’s concept of trimodal distribution of mortality secondary to trauma, proposed in 1983 [7]. This trimodal distribution of mortality remains a milestone in the trauma education and research, and is still actual for development but inconsistent for efficient trauma systems [8]. The concept of patients’ management in the prehospital setting covered a continuous interval, with two extremities: stay and play/treat then transfer or scoop and run/ load and go. Stay and play, usually used in Europe, implies airways securing and endotracheal intubation, pleurostomy tube insertion, and intravenous lines with volemic replacement therapy. During scoop and run, used in the Unites States, the patient is immediately transported to a trauma center, addressing the immediate life-threating injuries during transportation. In the emergency department of the corresponding trauma center, the resuscitation of the injured patients should be done by a trauma team, after an orchestrated protocol based on Advanced Trauma Life Support (ATLS). The modern trauma teams include five to ten specialists: general surgeons trained in trauma care, emergency medicine physicians, intensive care physicians, orthopedic surgeons, neurosurgeons, radiologists, interventional radiologists, and nurses. In the specially designed trauma centers, the leader of the trauma team should be the general surgeon, while in the lower level centers this role may be taken over by the emergency physicians. The implementation of a trauma system is a very difficult task, and should be tailored to the needs of the local population. For example, in Europe the majority of injuries are by blunt trauma, while in the United States or South Africa they are secondary to penetrating injuries. In an effort to analyse at a national level the performance of trauma care, we have proposed a national registry of major trauma patients [9]. For this registry we have defined major trauma as a New Injury Severity Score higher than 15. The maintenance of such registry requires significant human and financial resources, while only a permanent audit may decrease the rate of preventable deaths in the Romanian trauma care (Figure 1) [10]. Figure 1 - The website of Romanian Major Trauma Registry (http://www.registrutraume.ro). USA - In the United States of America there are 203 level I centers, 265 level II centers, 205 level III or II centers and only 32 level I or II pediatric centers, according to the 2014 report of National Trauma Databank [11]. USA were the first which recognized trauma as a public health problem, and proceeded to a national strategy for injury prevention, emergency medical care and trauma research. In 1966, the US National Academy of Sciences and the National Research Council noted that ‘’public apathy to the mounting toll from accidents must be transformed into an action program under strong leadership’’ [12]. Considerable national efforts were made in 1970s, when standards of trauma care were released and in 1990s when ‘’The model trauma care system plan’’[13] was generated. The American College of Surgeons introduced the concept of a national trauma registry in 1989. The National Trauma Databank became functional seven years later, in 2006 being registered over 1 million patients from 600 trauma centers [14]. Mortality from unintentional injury in the United States decreased from 55 to 37.7 per 100,000 population, in 1965 and 2004, respectively [15]. Due to this national efforts, 84.1% of all Americans have access within one hour from injury to a dedicated trauma care [16]. Canada - A survey from 2010 revealed that 32 trauma centers across Canada, 16 Level I and 16 Level II, provide definitive trauma care [18]. All these centers have provincial designation, and funding to serve as definitive or referral hospital. Only 18 (56%) centers were accredited by an external agency, such as the Trauma Association of Canada. The three busiest centers in Canada had between 798–1103 admissions with an Injury Severity Score over 12 in 2008 [18]. Australia - Australia is an island continent, the fifth largest country in the world, with over 23 million people distributed on this large area, a little less than the United States. With the majority of these citizens concentrated in large urban areas, access to the medical care for the minority of inhabitants distributed through the territory is quite difficult. The widespread citizens cannot be reached by helicopter, restricted to near-urban regions, but with the fixed wing aircraft of the Royal Flying Doctor Service, within two hours [13]. In urban centers, the trauma care is similar to the most developed countries, while for people sparse on large territories the trauma care is far from being managed in the ‘’golden hour’’, often extending to the ‘’Golden day’’ [19]. Germany - One of the most efficient European trauma system is in Germany. Created in 1975 on the basis of the Austrian trauma care, this system allowed an over 50% decreasing of mortality, despite the increased number of injuries. According to the 2014 annual report of the Trauma Register of German Trauma Society (DGU), there are 614 hospitals submitting data, with 34.878 patients registered in 2013 [20]. The total number of cases documented in the Trauma Register DGU is now 159.449, of which 93% were collected since 2002. In the 2014 report, from 26.444 patients with a mean age of 49.5% and a mean ISS of 16.9, the observed mortality was 10% [20]. The United Kingdom - In 1988, a report of the Royal College of Surgeons of England, analyzing major injuries concluded that one third of deaths were preventable [21]. In 2000, a joint report from the Royal College of Surgeons of England and of the British Orthopedic Association was very suggestive entitled "Better Care for the Severely Injured" [22]. Nowadays the Trauma Audit Research network (TARN) is an independent monitor of trauma care in England and Wales [23]. TARN collects data from hospitals for all major trauma patients, defined as those with a hospital stay longer than 72 hours, those who require intensive care, or in-hospital death. A recent analysis of TARN data, looking at the cost of major trauma patients revealed that the total cost of initial hospital inpatient care was £19.770 per patient, of which 62% was attributable to ventilation, intensive care and wards stays, 16% to surgery, and 12% to blood transfusions [24]. Global health care models Countries where is applied Functioning concept Total healthcare costs from GDP Bismarck model Germany Privatized insurance companies (approx. 180 nonprofit sickness funds). Half of the national trauma beds are publicly funded trauma centers; the remaining are non-profit and for-profit private centers. 11.1% Beveridge model United Kingdom Insurance companies are non-existent. All hospitals are nationalized. 9.3% National health insurance Canada, Australia, Taiwan Fusion of Bismarck and Beveridge models. Hospitals are privatized, but the insurance program is single and government-run. 11.2% for Canada The out-of-pocket model India, Pakistan, Cambodia The poorest countries, with undeveloped health care payment systems. Patients are paying for more than 75% of medical costs. 3.9% for India GDP – gross domestic product Table 1 - Global health care models with major consequences on trauma care [17]. Traumas continue to be a major healthcare problem, and no less important than cancer and cardiovascular diseases, and access to dedicated and timely intervention maximizes the patients’ chance for survival and minimizes the long-term morbidities. We should remember that one size does not fit in all trauma care. The Romanian National Trauma Program should tailor its resources to the matched demands of the specific Romanian urban and rural areas.

Стилі APA, Harvard, Vancouver, ISO та ін.

28

Leung, P., E. Lester, A. G. Doumouras, A. G. Doumouras, F. Saleh, S. Bennett, C. Fulton, et al. "2015 Canadian Surgery Forum02 The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks03 The association of change in body mass index and health-related quality of life in severely obese patients04 Inpatient cost of bariatric surgery within a regionalized centre of excellence system05 Regional variations in the public delivery of bariatric surgery: an evaluation of the centre of excellence model06 The effect of distance on short-term outcomes after bariatric surgery07 The role of preoperative upper endoscopy in bariatric surgery: a systematic review08 Outcomes of a dedicated bariatric revision surgery clinic10 Quality of follow-up: a systematic review of the research in bariatric surgery14 Bariatric surgery improves weight loss and cardiovascular disease compared with medical management alone: an Alberta multi-institutional early outcomes study16 Diabetic control after laparoscopic gastric bypass and sleeve gastrectomy: a short-term prospective study17 Knowledge and perception of bariatric surgery among primary care physicians: a survey of family doctors in Ontario19 Is early discharge of patients post laparoscopic sleeve gastrectomy safe?22 A comparison of outcomes between bariatric centres of excellence within Ontario02 Closure methods for laparotomy incisions: a cochrane review03 Closing the audit cycle: Are we consenting correctly now?05 Regional variation in the use of surgery in Ontario06 Quitting general surgery residency: attitudes and factors in Canada07 Nipple-sparing mastectomy: utility of intraoperative frozen section analysis of retroareolar tissue08 Withdrawn09 Reliable assessment of operative performance10 Video assessment as a method of assessing surgical competence: the difference in video-rating skills after 4 years of residency11 Burnout among academic surgeons13 Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study14 Novel models for advanced laparoscopic suturing: taking it to the next level16 Pectoral nerve block in breast and axillary surgery17 Predictors for positive resection margins in gastric adenocarcinoma: a population-based analysis18 Predictors of malignancy in thyroid nodules19 Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature20 Informed consent for surgery21 Meconium ileus: 20 years of experience22 Paraesophageal hernia repair in the elderly: outcomes in a 10-year retrospective study23 The changing face of breast cancer: younger age and aggressive disease in Filipino Canadians24 A systematic review of intraoperative blood loss estimation methods for major noncardiac surgery: a 50-year perspective25 The AVATAR trial: applying vacuum to accomplish reduced wound infections in laparoscopic pediatric surgery27 Indications for use of damage control surgery in civilian trauma patients: a content analysis and expert appropriateness rating study28 Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: a content analysis and expert appropriateness rating study29 The impact of health care contact and invasive procedures on Staphylococcus aureus bacteremia: a 5-year retrospective cohort study30 Acute care surgery — positive impact on gallstone pancreatitis31 Safety and efficacy of a step-up approach to management of severe, refractory Clostridium difficile infection32 Clinical and operative outcome of patients with acute cholecystitis who are treated initially with image-guided cholecystostomy34 Assessment of preoperative carbohydrate loading and blood glucose concentration in patients with diabetes35 Impact of pre-emptive lidocaine infiltration at trocar sites (PLITS) and intraoperative ketorolac administration on postoperative pain and narcotics consumption after endocholecystectomy: a randomized-controlled trial36 Expert intraoperative judgment and decision-making: defining the cognitive competencies for safe laparoscopic cholecystectomy37 Teaching clinical anatomy to postgraduate surgical trainees38 Investigating the role of TNFR1 in gastric adenocarcinoma peritoneal metastasis39 Selective outcome reporting and publication biases in surgical randomized controlled trials40 Definitive percutaneous management of symptomatic cholelithiasis41 Peer-based coaching: an innovative method to teach faculty an advanced laparoscopic technique42 Improving teaching and learning in the operating room: Does the surgical procedure feedback rubric support learning?43 Withdrawn44 Mislabelling study designs as case–control in surgical literature45 Measured resting energy expenditure in patients with open abdomens: preliminary data of a prospective pilot study46 Open abdomen management and primary abdominal closure in a surgical abdominal sepsis cohort: a retrospective review47 The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: a systematic review49 Program directors and trainees attitudes toward the introduction of multi-source feedback as part of surgical residents’ formative assessment process at the University of Calgary: a qualitative study50 Outcomes associated with alternate blunt cerebrovascular injury detection strategies in major trauma patients: a systematic review and meta-analysis51 Assessing the effect of preoperative nutrition on the surgical recovery of elderly patients53 Why is the percentage of medical students selecting a general surgery career different between Canadian medical schools?54 Colorectal cancer patient perspectives of preoperative repeat endoscopy: a qualitative study55 Staphylococcus aureus bacteremia in a pediatric population: a retrospective study in a tertiary-care referral centre56 The impact of postoperative complications on the recovery of elderly surgical patients57 Withdrawn58 The economics of recovery after pancreatic surgery: detailed cost minimization analysis of a postoperative clinical pathway for patients undergoing pancreaticoduodenectomy59 2015 CJS Editor’s Choice Award Recipient: Achalasia-specific quality of life after pneumatic dilation and laparoscopic Heller myotomy with partial fundoplication: a randomized clinical trial60 NSAID use is associated with an increased risk of anastomotic leak after colorectal surgery: results of a frequentist and Bayesian meta-analysis61 Miracles for babies with abnormal lungs: the story of miR-10a and lung development62 Investigating hospital readmissions and unplanned ED visits following general surgical procedures at a tertiary care centre63 Remote FLS testing: ready for prime time64 Contrast blush (CB) significance on computed tomography (CT) and correlation with noninterventional management (NIM) failure for blunt splenic injury (BSI) in children65 Bridging the gap on the surgical ward: enhancing resident–nurse communication through a CUSP pilot project66 A prospective interim analysis of microbiological gene expression profile of Staphyloccocus aureus bacteremia and its clinical implications67 Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis68 Does rater training improve the reliability of surgical skill assessments? A randomized control trial69 Parallel or divergent? The evolution of emergency general surgery service delivery at 3 Canadian teaching hospitals70 Surgeon satisfaction in the era of dedicated emergency general surgery services: a multicentre study74 Withdrawn76 Timing of cholecystectomy after gallstone pancreatitis: Are we meeting the standards?77 Management of traumatic occult hemothorax, a survey of trauma providers in Canada78 Withdrawn01 Extent of lymph node involvement after esophagectomy with extended lymphadenectomy for esophageal adenocarcinoma predicts recurrence: a large North American cohort study02 A randomized comparison of electronic versus handwritten daily notes in thoracic surgery03 Is tissue still the issue? Lobectomy for suspected lung nodules without preoperative or intraoperative confirmation of malignancy04 Incidence of pulmonary embolism and deep vein thrombosis following major lung resection: a prospective multicentre incidence study05 Venous thromboembolism (VTE) prophylaxis in thoracic surgery: a Canadian national delphi consensus survey06 Preoperative chemoradiation therapy v. chemotherapy in patients undergoing modified en bloc esophagectomy for locally advanced esohageal adenocarcinoma: Does radiation add value?07 Comparative outcomes following tracheal resection for benign versus malignant conditions08 Combined clinical staging for resectable lung cancer: clinicopathological correlations and the role of brain MRI10 A retrospective cohort evaluation of non–small cell lung cancer recurrence detection11 Health-related quality of life measure distinguishes between low and high T stages in esophageal cancer12 Transition from multiport to single-port anatomic lung resection is feasible13 Survival rates in patients with N3 esophageal adenocarcinoma treated with neoadjuvant chemotherapy and esophagectomy with en-bloc lymphadenectomy14 Impact of a dedicated outpatient clinic on the management of malignant pleural effusions16 Has the quality of reporting of randomized controlled trials in thoracic surgery improved?17 Clinical features distinguishing malignant from benign esophageal diagnoses in patients referred to an esophageal diagnostic assessment program18 Concordance with invasive mediastinal staging guidelines19 Current lung-protective ventilation strategies may not be protective during one-lung ventilation surgery20 National practice variation in pneumonectomy perioperative care — results from a survey of the Canadian Association of Thoracic Surgeons21 Outcomes after multimodal treatment of esophagogastric neuroendocrine carcinoma: Is there a role for resection?22 Clinical results of treatment for isolated axillary and plantar hyperhidrosis: a single centre experience23 The role of pneumonectomy after neoadjuvant chemotherapy for N2 non–small cell lung cancer24 Time delays in the management of non–small cell lung cancer: a comparison between high-volume designated and low-volume community hospitals25 Regionalization and outcomes of lung cancer surgery in Ontario, Canada26 Robotic pulmonary resection for lung cancer: the first Canadian series01 The effect of early postoperative nonsteroidal anti-inflammatory drugs on pancreatic fistula following pancreaticoduodenectomy02 Laparoscopic ultrasound still has a role in the staging of pancreatic cancer: a systematic review of the literature03 Impact of portal vein embolization on morbidity and mortality of major liver resection in patients with colorectal metastases: experience of a small single tertiary care centre04 A decision model and cost analysis of intraoperative cell salvage during hepatic resection05 The impact of portal pedicle clamping on survival from colorectal liver metastases in the contemporary era of liver resection: a matched cohort study06 Clinical and pathological features of intraductal papillary neoplasms of the biliary tract and gallbladder07 International practice patterns among ALPPS surgeons: Do we need a consensus?08 Omental flaps to protect pancreaticojejunostomy in pancreatoduodenectomy11 Preoperative diagnostic angiogram and endovascular aortic stent placement for appleby resection candidates: a novel surgical technique in the management of locally advanced pancreatic cancer12 Recurrence following initial hepatectomy for colorectal liver metastases: a multi-institutional analysis of patterns, prognostic factors and impact on survival13 The influence of the multidisciplinary cancer conference era on the management of colorectal liver metastases14 Monosegment ALPPS hepatectomy: extending resectability by rapid hypertrophy15 How does simultaneous resection of colorectal liver metastases impact chemotherapy administration?16 Preoperative liver volumetry for surgical planning: a systematic review and evaluation of current modalities17 Surgical planning of hepatic metastasectomy using radiologist performed intraoperative ultrasound21 Surgical resection and perioperative chemotherapy for colorectal cancer liver metastases: a population-based study22 Management and outcome of colorectal cancer (CRC) liver metastases in the elderly: a population-based study23 Outcomes following repeat hepatic resection for recurrent metastatic colorectal cancer: a population-based study24 A clinical pathway after pancreaticoduodenectomy standardizes postoperative care and may decrease postoperative complications25 Significance of regional lymph node involvement in patients undergoing liver resection and lymphadenectomy for colorectal cancer metastases26 NSAID use and risk of postoperative pancreatic fistulas following pancreaticoduodenectomy: a retrospective cohort study27 Minimally invasive HPB surgery in Canada: What are we doing and do we want to do more?28 2015 CJS Editor’s Choice Award Recipient: Predictors of actual survival in resected pancreatic adenocarcinoma: a population-level analysis29 Predictors of receipt of adjuvant therapy following pancreatic adenocarcinoma resection: a population-based analysis30 Effect of surgical wait time on oncological outcomes in periampullary cancer31 Does surgical assist expertise affect resectability in periampullary malignancies?32 The impact of tranexamic acid on fibrinolytic activity during major liver resection33 Colorectal cancer with synchronous hepatic metastases: a national survey of opinions on treatment sequencing and multidisciplinary cooperation34 Outcomes associated with a matched series of patients undergoing sequential resections of colorectal cancer and hepatic metastases compared with synchronous surgical therapy of the primary and hepatic metastases35 The impact of anesthetic inhalational agent on short-term outcomes after liver resection38 The impact of perioperative blood transfusions on posthepatectomy short-term outcomes: an analysis from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)39 Associations between pancreatic cancer quality indicators and outcomes in Nova Scotia40 Developing a national quality agenda in hepato-pancreato-biliary surgery: key priority areas for study02 Withdrawn03 Histological features and clinical implications of polypropylene degradation04 A rare case of primary hernia of the perineum05 Migration of polypropylene mesh in the development of late complications06 Laparoscopic hernia repair — Has this procedure run its course?07 Mesh materials used for hernia repair: Why do they shrink?08 The role of pure tissue repairs in a tailored concept for inguinal hernia repair09 Recurrent inguinal hernias a persistent problem in hernia surgery: analysis of 14 640 recurrent cases in the German hernia database, Herniamed10 Open circular intra-abdominal ventral herniorrhaphy: a new technique in ventral hernia repair01 Misrepresentation or “spin” is common in robotic colorectal surgical studies02 Postoperative pelvic sepsis rates following complete pathologic response to neoadjuvant therapy in rectal cancer03 Understanding the complexities of shared decision-making in cancer: a qualitative study of the perspectives of patients undergoing colorectal surgery04 Impact of hospital volume on quality indices for rectal cancer surgery in British Columbia, Canada07 The effect of laparoscopy on inpatient cost after elective colectomy for colon cancer08 Predictors of variation in neighbourhood access to laparoscopic colectomy for colon cancer09 Predictors of 30-day readmission after elective colectomy for colon cancer10 Neutrophil-to-lymphocyte ratio predicts major perioperative complications in patients with colorectal cancer12 Sessile serrated adenoma (SSA) detection-predictive factors13 Diverticular abscess managed with long-term definitive nonoperative intent is safe14 Long-term outcomes of conservative management following successful nonoperative treatment of acute diverticulitis with abscess: a systematic review15 Incidence of ischemic colitis after abdominal aortic aneurysm repair: results from the national surgical quality improvement program database16 Sigmoid colectomy for acute diverticulitis in immunosuppressed v. immunocompetent patients: outcomes from the ACS-NSQIP database17 A cross-sectional survey of health and quality of life of patients awaiting colorectal surgery in Canada19 Self-expanding metal stents versus emergent surgery in acute malignant large bowel obstruction20 Combined laparoscopic and TAMIS LAR in a morbidly obese patient after open right hepatectomy21 Safety and feasibility of laparoscopic rectal cancer resection in morbidly obese patients22 Factors associated with morbidity following sacral neurostimulation for fecal incontinence: beware of the high risk groups23 Hyperglycemia increases surgical site infections following colorectal resections for malignancy in a standardized patient cohort24 Implementing an enhanced recovery program after colorectal surgery in elderly patients: Is it feasible?25 From laparoscopic-assisted to total laparoscopic right colectomy with intracorporeal anastomosis: Is the shift in technique justified?26 Surgical site infection rates following implementation of a “colorectal closure bundle” in elective colorectal surgeries27 Quality of life and anorectal function of rectal cancer patients in long-term recovery28 Combined laparoscopic/transanal endoscopic microsurgery approach to radical resection for rectal tumours29 Transanal endoscopic microsurgery resection of rectal neuroendocrine tumours: a single centre Canadian experience30 Abdominoperineal reconstruction with a myocutaneous flap32 Comparison of robotic and laparoscopic colorectal surgery with respect to 30-day perioperative morbidity33 Definitive management of fistula-in-ano using draining setons35 Oncologic outcomes following complete pathologic response to neoadjuvant therapy in rectal cancer36 Laparoscopic total mesorectal excision in obese patients with rectal cancer: What is the oncological impact?38 Improving the enhanced recovery programs in laparoscopic colectomy: liposomal bupivacaine may not be the answer39 Fistulae related to colonic diverticular disease: a single institution experience41 Laparoscopic colectomy for malignancy provides similar pathologic outcomes and improved survival outcomes compared with open approaches42 MRI utilization and completeness of reporting in rectal cancer: a population-based study43 Supporting quality assurance initiatives for rectal cancer: Is the CAP protocol enough?44 Accuracy and predictive ability of preoperative MRI for rectal adenocarcinoma: room for improvement47 A population-based study of colorectal cancer in patients ≤ 40: Does the extent of resection affect outcomes?48 Transanal minimally invasive surgery (TAMIS) for rectal neoplasms01 The impact of blood transfusion on perioperative outcomes following resection of gastric cancer: an analysis of the ACS-NSQIP02 Association of wait time to surgical management with overall survival in Ontarians with melanoma04 General surgeons’ attitudes toward breast reconstruction in the province of Quebec06 Neoadjuvant chemotherapy for breast cancer: Is practice changing? A population-based review of current surgical trends07 Robotic versus laparoscopic versus open gastrectomy for gastric adenocarcinoma15 Influence of preoperative MRI on the surgical management of breast cancer patients17 Adverse events related to lymph node dissection for cutaneous melanoma: a systematic review and meta-analysis19 Regional variations in survival, case volume and intraoperative margin assessment in resected gastric cancer20 Comparison of clinical and economic outcomes between robotic, laparoscopic and open rectal cancer surgery: early experience at a tertiary care centre21 Outcomes and clinicopathologic features of patients with Angiosarcoma of the breast23 Postmastectomy radiation: Should subtype factor in to the decision?24 Omission of axillary staging in elderly patients with early stage breast cancer impacts regional control but not survival: a systematic review and meta-analysis25 Objective pathological assessment of CRCLM by MALDI26 Identification of predictive tumour markers in breast cancer tissue — a pilot study research plan27 Reframing women’s risk: counselling on contralateral prophylactic mastectomy in non–high risk women with early breast cancer28 Withdrawn30 Comparison of different methods of immediate breast reconstructions for breast cancer patients: Is “single stage” really better?32 Is lymph node ratio a more accurate prognostic factor in stage III colon cancer than standard nodal staging?33 Costs associated with reoperation in the setting of attempted breast-conserving surgery: a decision analysis34 Polo-like kinase 4 (Plk4) activates Cdc42, stimulates cell invasion and enhances cancer progression in vivo35 Negative predictive value of preoperative abdominal CT in determining gastric cancer resectability on a population level36 2015 CJS Editor’s Choice Award Recipient: (18)F-fluoroazomycin arabinoside positron emission tomography (FAZA-PET) imaging predicts response to chemoradiation and evofosfamide (TH-302) in a preclinical xenograft model of rectal cancer37 Impact of a regional guideline on the surgical treatment of the axilla in patients with breast cancer: a population-based study39 Recent trends in port-site metastasis following laparoscopic resection of gallbladder cancer: a systematic review40 Real-time electromagnetic navigation for breast tumour resection: pilot study on palpable tumours41 Neoadjuvant imatinib for primary gastrointestinal stromal tumour (GIST): mutational status and timing of resection42 Adherence to osteoporosis screening guidelines in seniors with breast cancer treated with anti-estrogen therapy: a population-based study43 Automated robot interventions for enhanced clinical outcomes in breast biopsy44 Preoperative pregabalin or gabapentin for postoperative acute and chronic pain among patients undergoing breast cancer surgery: a systematic review and meta-analysis of randomized controlled trials46 Uptake and impact of synoptic reporting on breast cancer operative reports in a community care setting47 Withdrawn." Canadian Journal of Surgery 58, no. 4 Suppl 2 (August 2015): S169—S238. http://dx.doi.org/10.1503/cjs.008615.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

29

Brière, Raphaëlle, Rogeh Habashi, Shaila Merchant, Lina Cadili, Zainab Alhumoud, Rebecca Lau, Nada Gawad та ін. "2023 Canadian Surgery Forum01. Evaluation of physicians’ practices and knowledge regarding the treatment of acute uncomplicated diverticulitis03. What is the effect of rurality on outcomes for parathyroidectomy in a large North American jurisdiction?05. Characteristics of opioid providers for patients undergoing same-day breast surgery in Ontario, Canada06. Improving the management and outcomes of complex non-pedunculated colorectal polyps at a regional hospital in British Columbia10. Actinomycosis presenting as an anterior abdominal mass after laparoscopic cholecystectomy12. Prioritizing melanoma surgeries to prevent wait time delays and upstaging of melanoma during the COVID-19 pandemic13. Trust me, I know them: assessing interpersonal bias in general surgery residency interviews14. Current state of female and BIPOC representation in Canadian academic surgical societies15. Harnessing a province-wide network of surgical excellence and diverse talents for the continuous improvement of surgical care in BC16. Massive stone or is it glass: a curious case of porcelain gallbladder17. Choosing your endoscopist: a retrospective single-centre cohort study18. The local experience with endoscopic ampullectomy for noninvasive ampullary lesions at a single tertiary care centre19. Defining appropriate intraoperative patient blood management strategies in noncardiac surgery: the Ottawa Intraoperative Transfusion Consensus20. Postoperative gastrointestinal dysfunction after neuromuscular blockade reversal with sugammadex versus cholinesterase inhibitors in patients undergoing gastrointestinal surgery: a systematic review and meta-analysis21. Factors influencing recurrence in medial breast cancer after skin-sparing mastectomy and immediate breast reconstruction22. What is the role of fit in medical education? A scoping review23. The obesity paradox revisited: Is obesity still a protective factor for patients with severe comorbidities or in high-risk operations?24. Planetary health education for residents — an integrative approach through quality improvement25. A rare case of concurrent primary malignancies: adrenal cortical carcinoma and metastatic colon cancer26. Effect of video-based self-assessment on intraoperative skills: a pilot randomized controlled trial28. A cost–utility study of elective hemorrhoidectomies in Canada30. Opioid-free hernia repair using local anesthetic: an assessment of postoperative pain and recovery31. Mitigating the environmental burden of surgical and isolation gowns33. The evolution and contributions of theCanadian Journal of Surgery: a bibliometric study34. Clinical and oncologic outcomes of patients with rectal cancer and past radiotherapy for prostate cancer: a case–control study35. Antibiotic prophylaxis and mechanical bowel preparation in elective colorectal surgery: a survey of Quebec general surgeons36. Identifying core deficiencies and needs in the surgical knot-tying curriculum: a single-centre qualitative analysis37. Spleen-preserving surgery for symptomatic benign splenic cyst: video case report38. Learning to manage power differentials and navigate uncertainty: a qualitative interview study about decision-making in surgery39. Surgical education checklist: a novel tool to improve uptake of Competence By Design in a residency program and surgical resident experience40. A comparative evaluation of management strategies and patient outcomes for acute appendicitis in the post-COVID era41. External benchmarking of colorectal resection outcomes using ACS-NSQIP: accurately categorizing procedures at risk of morbidity42. Role of thymectomy in surgical treatment of secondary and tertiary hyperparathyroidism43. Starting position during colonoscopy: a systematic review and meta-analysis of randomized controlled trials44. Enhanced Recovery After Surgery protocols following emergency intra-abdominal surgery reduces length of stay and postoperative morbidity: a systematic review and meta-analysis45. Competencies, privileging and geography: preparing general surgery residents for rural practice in British Columbia46. Holographic surgical skills training: Can we use holograms to teach hand ties and is it comparable to in-person learning?47. The association between gender and confidence in UBC general surgery residents48. Quality improvement in timeliness of EPA completion in general surgery residency49. Gastrointestinal system surgical outcomes in the highly active antiretroviral therapy (HAART)-era HIV-positive patient: a scoping review50. Joint rounds as a method to partner surgical residency programs and enhance global surgical training52. Preoperative frailty and mortality in medicare beneficiaries undergoing major and minor surgical procedures53. What’s going on out there? Evaluating the scope of rural general surgery in British Columbia54. Short-stay compared with long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis55. General surgeons’ right hemicolectomy costs proficiency and preferences56. Staple line with bioabsorbable reinforcement for gastropexy in hiatal hernia repair57. Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review58. Evaluation of outcomes between rural, northern/remote, and urban surgical patients diagnosed with moderate to severe acute pancreatitis: a retrospective study59. Outcome of preoperative percutaneous drainage of intraabdominal abscess versus initial surgery in patients with Crohn disease60. Preliminary analysis: dexamethasone-supplemented TAP blocks may reduce opioid requirements after colorectal surgery: a multi-centre randomized controlled trial61. Preoperative skin preparation with chlorhexidine alcohol versus povidone–iodine alcohol for the prevention of surgical site infections: a systematic review and meta-analysis of randomized controlled trials62. “Why didn’t you call me?” Factors junior learners consider when deciding whether to call their supervisor63. Cost savings associated with general surgical consultation within remote Indigenous communities in Quebec: a costing evaluation64. Right lateral decubitis patient position during colonoscopy increases endoscopist’s risk of musculoskeletal injury65. Reducing re-visit to hospital rates among pediatric post-appendectomy patients: a quality-improvement project66. Exploring gender diversity in surgical residency leadership across Canada67. Operating room sustainability project: quantifying the surgical environmental footprint for a laparoscopic cholecystectomy in 2 major surgical centres68. ERCP under general anesthesia compared with conscious sedation (EUGACCS) study69. Complications requiring intervention following gastrostomy/gastrojejunostomy tube insertion: a retrospective analysis70. Equity, diversity and inclusion (EDI) in underrepresented in medicine (URiM) residents: Where are we and what now?71. Association between complications and death within 30 days after general surgery procedures: a Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) substudy72. What is the long-term impact of gastrograffin on adhesive small bowel obstruction? A systematic narrative review73. TRASH-CAN: Trainee-Led Research and Sudit for Sustainability in Healthcare Canada74. Representation and reporting of sociodemographic variables in BREAST-Q studies: a systematic review75. A scoping review: should tap water instead of sterile water be used for endoscopy of the colon and rectum?76. Laparoscopic revision of Nissen fundoplication with EndoFLIP intraoperative assistance: a video presentation77. Environmental sustainability in the operating room: perspectives and practice patterns of general surgeons in Canada78. The impact of COVID-19 on medical students applying to general surgery in the CaRMS matching process79. Novel approach to laparoscopic gastrostomy tube placement80. Using prucalopride for prevention of postoperative ileus in gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials81. Assessment of environmental and economic sustainability of perioperative patient warming strategies83. Development of a Canadian colorectal robotic surgery program: the first three years84. Patient safety and quality improvement lessons from review of Canadian thyroid and parathyroid surgery malpractice litigation case law01. Changes in sarcopenia status predict survival among patients with resectable esophageal cancer02. The feasibility of near-infrared fluorescence-guided robotic-assisted minimally invasive esophagectomy using indocyanine green dye03. Does patient experience with robotic thoracic surgery influence their willingness to pay for it?04. Artificial intelligence–augmented endobronchial ultrasound-elastography is a useful adjunct for lymph node staging for lung cancer05. Preoperative mediastinal staging in early-stage lung cancer: targeted nodal sampling is not inferior to systematic nodal sampling06. The application of an artificial intelligence algorithm to predict lymph node malignancy in non-small cell lung cancer07. Pneumonectomy for non-small cell lung cancer: long-term overall survival from a 15-year experience09. Primary spontaneous pneumothorax occurred in pectus excavatum patients10. Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program11. Needle decompressions in post-traumatic tension pneumothorax: boon or bane12. 10-year follow-up of endoscopic mucosal resection versus esophagectomy for esophageal intramucosal adenocarcinoma in the setting of Barrett esophagus: a Canadian experience13. Outcomes after thoracic surgery for malignancy in patients with severe and persistent mental illness15. Stage II/III esophageal cancer patients with complete clinical response after neoadjuvant chemoradiotherapy: a Markov decision analysis16. Development of a surgical stabilization of rib fractures program at a Level I trauma centre in Qatar: initial report17. Screening Criteria Evaluation for Expansion in Pulmonary Neoplasias (SCREEN) II18. Multi-centre study evaluating the risks and benefits of intraoperative steroids during pneumonectomy19. Prediction of esophageal cancer short-term survival using a pretreatment health-related quality of life measure20. Evaluating the impact of virtual care in thoracic surgery: patients’ perspective21. Virtual thoracic surgical outpatient encounters are non-inferior to in-person visits for overall patient care satisfaction in the post-COVID-19 era22. Concurrent minimally invasive esophagectomy and laparoscopic right hemicolectomy23. Assessing the impact of robotic-assisted thoracic surgery on direct carbon dioxide emissions — a retrospective analysis of a prospective cohort24. Young’s modulus of human lung parenchyma and tumours25. Thoracic surgery trauma: nail gun v. SVC26. Thymomatous myasthenia gravis after total thymectomy at a tertiary care surgical centre: a 15-year retrospective review27. Effectiveness of 18F-FDG-PET/CT in the stage diagnosis of non-small cell lung cancer (NSCLC): a diagnostic test accuracy systematic review and meta-analysis01. Emergency colon resection in the geriatric population: the modified frailty score as a risk factor of early mortality02. Laparoscopic ovarian transposition prior to pelvic radiation in young female patients with anorectal malignancies: a systematic review and meta-analysis of prevalence03. Using preoperative C-reactive protein levels to predict anastomotic leaks and other complications after elective colorectal surgery: a systematic review and meta-analysis04. Perioperative intravenous dexamethasone for patients undergoing colorectal surgery: a systematic review and meta-analysis05. Population-based study comparing time from presentation to diagnosis and treatment between younger and older adults with colorectal cancer06. The role of warmed-humidified CO₂insufflation in colorectal surgery: a meta-analysis07. Total abdominal colectomy versus diverting loop ileostomy and antegrade colonic lavage for fulminantClostridioidescolitis: analysis of the national inpatient sample 2016–201908. Cutting seton for the treatment of cryptoglandular fistula-inano: a systematic review and meta-analysis09. Prognostic value of routine stain versus elastic trichrome stain in identifying venous invasion in colon cancer10. Anastomotic leak rate following the implementation of a powered circular stapler in elective colorectal surgeries11. Surgical technique and recurrence of Crohn disease following ileocolic resection12. Implementation of synoptic reporting for endoscopic localization of complex colorectal neoplasms: Can we reduce rates of repeat preoperative colonoscopy?13. Effects of diet and antibiotics on anastomotic healing: a mouse model study with varied dietary fibre and fat, and preoperative antibiotics14. Assessment of rectal surgery–related physical pain and conditioning: a national survey of Canadian rectal surgeons15. Does specimen extraction incision and transversus abdominis plane block affect opioid requirements after laparoscopic colectomy?16. Colorectal and therapeutic GI working together: What is the role for TAMIS for benign lesions?17. Impact of the COVID-19 pandemic on readmission rates following colorectal surgery18. More than the sum of its parts: the benefits of multidisciplinary conferences extend beyond patient care19. Multidisciplinary conference for rectal cancer — measuring patient care impact20. Patient outcomes in emergency colorectal cancer resections: a 15-year cohort analysis21. Enhanced Recovery after Surgery (ERAS) protocols in colorectal cancer resection: a 15-year analysis of patient outcomes22. Laparoscopic to open conversion in colorectal cancer resection: a 15-year analysis of postoperative outcomes23. Management of postoperative ileus in colorectal cancer resections: a 15-year evaluation of patient outcomes24. Timing of ostomy reversal and associated outcomes: a systematic review25. Fragility of statistically significant outcomes in colonic diverticular disease randomized trials26. Postoperative day 1 and 2 C-reactive protein values for predicting postoperative morbidity following colorectal surgery27. Bariatric surgery before colorectal surgery reduces postoperative morbidity and health care resource utilization: a propensity score matched analysis28. Ileocolic Crohn disease: a video vignette of the Kono-S anastomosis29. Association between patient activation and postoperative outcomes in rectal cancer survivors30. Understanding surgeon and nurse perspectives on the use of patient-generated data in the management of low anterior resection syndrome31. Characteristics of interval colorectal cancer: a Canadian retrospective population-level analysis from Newfoundland and Labrador32. Current rectal cancer survivorship care: unmet patient needs and fragmented specialist and family physician care33. Local excision for T1 rectal cancer: a population-based study of practice patterns and oncological outcomes34. Can nonoperative management of acute complicated diverticulitis be successfully treated with a future hospital at home program? A retrospective cohort study35. Does patient activation impact remote digital health follow-up and same-day discharge after elective colorectal surgery36. Parastomal hernia prevention, assessment and management: best practice guidelines37. Anastomotic leak rates in circular powered staplers versus manual circular staplers in left sided colorectal anastomoses: a systematic review38. The Gips procedure for pilonidal disease: a video presentation39. Local recurrence-free survival after transanal total mesorectal excision: a Canadian institutional experience40. The impact of operative approach for obese colorectal cancer patients: analysis of the national inpatient sample (2015–2019)41. Safety and feasibility of discharge within 24 hours of colectomy: a systematic review and meta-analysis42. Laparoscopic lateral lymph node dissection for an advanced rectal cancer: a video abstract43. “Dear diary”: challenges in adopting routine operative recording in surgical training44. Rectal cancer in the very young (age < 40) — more treatment, worse survival: a population-based study45. Surveillance following treatment for stage I–III rectal cancer in Ontario — a population-based descriptive study46. A 15-year institutional experience of trananal endoscopic microsurgery for local excision of benign and malignant rectal neoplasia47. Robotic approach to reoperative pelvic surgery48. A mucosa-adherent bacterium impairs colorectal anastomotic healing by upregulating interleukin-17: the role of low-grade inflammation as a driver of anastomotic leak49. High uptake of total neoadjuvant therapy for rectal cancer in Canada despite surgeon concerns for possible overtreatment and treatment-related toxicity50. Safety and feasibility of discharge within 24 hours of ileostomy reversal: a systematic review and meta-analysis51. Safety and efficacy of intravenous antifibrinolytic use in colorectal surgery: systematic review and meta-analysis52. Impact of ileal pouch anal anastomosis on fertility in female patients with uulcerative colitis: a systemic review53. Modulation of the gut microbiota with fermentable fibres and 5-aminosalicylate to prevent peri-anastomotic and metastatic recurrence of colorectal cancer54. Patients with locally advanced rectal cancer and a non-threatened circumferential resection margin may go straight to surgery and avoid radiation toxicities: the QuickSilver Trial55. Colonoscopies during the COVID-19 pandemic recovery period: Are we caught up on colorectal cancer detection and prevention? A single-institution experience56. Interim results of a phase II study evaluating the safety of nonoperative management for locally advanced low rectal cancer57. Assessing a tailored curriculum for endoscopic simulation for general surgery residency programs in Canada58. Modified Frailty Index for patients undergoing surgery for colorectal cancer: analysis of the National Inpatient Sample (2015–2019)59. Reducing postoperative bloodwork in elective colorectal surgery: a quality-improvement initiative60. A Nationwide Readmission Database (NRD) analysis assessing timing of readmission for complications following emergency colectomy: why limiting follow-up to postoperative day 30 underserves patients61. The same but different: clinical and Enhanced Recovery After Surgery outcomes in right hemicolectomy for colon cancer versus ileocecal resection in Crohn disease01. How reliable are postmastectomy breast reconstruction videos on YouTube?02. Knowledge, perceptions, attitudes, and barriers to genetic literacy among surgeons: a scoping review03. Exploring neutrophil-to-lymphocyte ratio as a predictor of postoperative breast cancer overall survival04. High β integrin expression is differentially associated with worsened pancreatic ductal adenocarcinoma outcomes05. Epidemiology of undifferentiated carcinomas06. An evidence-based approach to the incorporation of total neoadjuvant therapy into a standardized rectal cancer treatment algorithm07. Pushing the boundaries: right retroperitoneoscopic adrenalectomy after laparoscopic right nephrectomy08. The role of caspase-1 in triple negative breast cancer, the immune tumour microenvironment and response to anti-PD1 immunotherapy09. Perioperative neutrophil-to-lymphocyte ratio is associated with survival in patients undergoing colorectal cancer surgery10. Achievement of quality metrics in older adults undergoing elective colorectal cancer surgery11. Opportunities to improve the environmental sustainability of breast cancer surgical care12. Does margin status after biopsy matter in melanoma? A cohort study of micro- and macroscopic margin status and their impact on residual disease and survival13. Demonstration of D2 Lymph node stations during laparoscopic total gastrectomy14. Incidence of metastatic tumours to the ovary (Krukenberg) versus primary ovarian neoplasms associated with colorectal cancer surgery15. Spatial biomarkers in cancer16. How informed is the consent process for complex cancer resections?17. Adjuvant radiation therapy among immigrant and Canadian-born/long-term resident women with breast cancer18. Human peritoneal explant model reveals genomic alterations that facilitate peritoneal implantation of gastric cancer cells19. Preoperative breast satisfaction association with major complications following oncologic breast surgery20. Impact of geography on receipt of medical oncology consultation and neoadjuvant chemotherapy for triple negative andHER2positive breast cancer21. Comparison of radiation, surgery or both in women with breast cancer and 3 or more positive lymph nodes22. Impact of synoptic operative reporting as a quality indicator for thyroid surgery: a Canadian national study01. The Toronto management of initially unresectable liver metastases from colorectal cancer in a living donor liver transplant program02. Dissection of a replaced right hepatic artery arising from the superior mesenteric artery during a laparoscopic Whipple03. Implementing the HIBA index: a low-cost method for assessing future liver remnant function04. Oncologic outcomes after surgical resection versus thermoablation in early-stage hepatocellular carcinoma: a systematic review of randomized controlled trials with meta-analysis05. Robotic pancreatic necrosectomy and internal drainage for walled-off pancreatic necrosis06. Predicting diabetes mellitus after partial pancreatectomy: PRIMACY, a pilot study07. Bleed and save: patient blood management in hepatectomy08. Defining standards for hepatopancreatobiliary cancer surgery in Ontario, Canada: a population-based cohort study of clinical outcomes09. Laparoscopic choledochoduodenostomy for recurrent choledocholithiasis10. A comparison of daytime versus evening versus overnight liver transplant from a single Canadian centre11. Pilot study validating the line of safety as a landmark for safe laparoscopic cholecystectomy using indocyanine green and near-infrared imagine12. Effect of transversus abdominis plane catheters on postoperative opioid consumption in patients undergoing open liver resections — a single-centre retrospective review13. Comparing the RETREAT score to the Milan criteria for predicting 5-year survival in post-liver transplant hepatocellular carcinoma patients: a retrospective analysis14. Characterizing the effect of a heat shock protein-90 inhibitor on porcine liver for transplantation using ex-vivo machine perfusion15. Modulation by PCSK9 of the immune recognition of colorectal cancer liver metastasis17. Implementation of a preoperative ketogenic diet for reduction of hepatic steatosis before hepatectomy19. Trends in the incidence and management of hepatocellular carcinoma in Ontario20. Canadian coaching program leads to successful transition from open to laparoscopic hepatopancreatobiliary surgery21. The impact of a positive pancreatic margin analyzed according to LEEPP on the recurrence and survival of patients with pancreatic head adenocarcinoma22. Armed oncolytic virus VSV-LIGHT/TNFSF14 promotes survival and results in complete pathological and radiological response in an immunocompetent model of advanced pancreatic cancer23. Comparing the efficacy of cefazolin/metronidazole, piperacillin-tazobactam, or cefoxitin as surgical antibiotic prophylaxis in patients undergoing pancreaticoduodenectomy: a retrospective cohort study01. Not just jumping on the bandwagon: a cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded health care system02. Shouldice method brief educational video03. Laparoscopic recurrent hiatal hernia repair with mesh gastropexy04. Robotic transabdominal preperitoneal Grynfeltt lumbar hernia repair with mesh01. Substance abuse screening prior to bariatric surgery: an MBSAQIP cohort study evaluating frequency and factors associated with screening02. MBSAQIP risk calculator use in elective bariatric surgery is uncommon, yet associated with reduced odds of serious complications: a retrospective cohort analysis of 210 710 patients03. Short-term outcomes of concomitant versus delayed revisional bariatric surgery after adjustable gastric band removal04. Safety and outcomes of bariatric surgery in patients with inflammatory bowel disease: a systematic review and meta-analysis08. Prescription drug usage as measure of comorbidity resolution after bariatric surgery — a population-based cohort study09. Experiences and outcomes of Indigenous patients undergoing bariatric surgery: a mixed-methods scoping review10. Bariatric surgery reduces major adverse kidney events in patients with chronic kidney disease: a multiple-linked database analysis in Ontario11. Inter-rater reliability of indocyanine green fluorescence angiography for blood flow visualization in laparoscopic Roux-en-Y gastric bypass12. Characterization of small bowel obstructions following elective bariatric surgery13. Revision of bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients14. Duodenal-jejunal bypass liners are superior to optimal medical management in ameliorating metabolic dysfunction: a systematic review and meta-analysis15. Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10 589 patients01. Collateral damage: the impact of the COVID-19 pandemic on the severity of abdominal emergency surgery at a regional hospital02. Pseudoaneurysms after high-grade penetrating solid organ injury and the utility of delayed CT angiography03. Pseudoaneurysm screening after pediatric high-grade solid organ injury04. Witnessed prehospital traumatic arrest: predictors of survival to hospital discharge05. A tension controlled, noninvasive device for reapproximation of the abdominal wall fascia in open abdomens08. Delayed vs. early laparoscopic appendectomy (DELAY) for adult patients with acute appendicitis: a randomized controlled trial09. Days at home after malignant bowel obstructions: a patient-centred analysis of treatment decisions10. Polytrauma and polyshock: prevailing puzzle11. National emergency laparotomy audit: a 9-year evaluation of postoperative mortality in emergency laparotomy13. A comparison of stress response in high-fidelity and low-fidelity trauma simulation14. ASA versus heparin in the treatment of blunt cerebrovascular injury — a systematic review and meta-analysis15. Comparison of complication reporting in trauma systems: a review of Canadian trauma registries16. Benefits of the addition of a nurse practitioner to a high-volume acute care surgery service: a quantitative survey of nurses, residents and surgery attendings17. Examining current evidence for trauma recurrence preventions systems18. Disparities in access to trauma care in Canada: a geospatial analysis of Census data19. Fast-track pathway to accelerated cholecystectomy versus standard of care for acute cholecystitis: the FAST pilot trial20. Using the modified Frailty Index to predict postoperative outcomes in patients undergoing surgery for adhesive small bowel obstruction: analysis of the National Inpatient Sample, 2015–201921. Adequacy of thromboprophylaxis in trauma patients receiving conventional versus higher dosing regimens of low-molecular-weight heparin: a prospective cohort study22. The hidden epidemiology of trauma in Nunavik: a comparison of trauma registries as a call to action23. Mapping surgical services in rural British Columbia: an environmental scan". Canadian Journal of Surgery 66, № 6 Suppl 1 (8 грудня 2023): S53—S136. http://dx.doi.org/10.1503/cjs.014223.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

30

Hoit, G., C. Hinkewich, J. Tiao, V. Porgo, L. Moore, L. Moore, J. Tiao, et al. "Trauma Association of Canada (TAC) Annual Scientific Meeting. The Westin Whistler Resort & Spa, Whistler, BC, Thursday, Apr. 11 to Saturday, Apr. 13, 2013Testing the reliability of tools for pediatric trauma teamwork evaluation in a North American high-resource simulation settingThe association of etomidate with mortality in trauma patientsDefinition of isolated hip fractures as an exclusion criterion in trauma centre performance evaluations: a systematic reviewEstimation of acute care hospitalization costs for trauma hospital performance evaluation: a systematic reviewHospital length of stay following admission for traumatic injury in Canada: a multicentre cohort studyPredictors of hospital length of stay following traumatic injury: a multicentre cohort studyInfluence of the heterogeneity in definitions of an isolated hip fracture used as an exclusion criterion in trauma centre performance evaluations: a multicentre cohort studyPediatric trauma, advocacy skills and medical studentsCompliance with the prescribed packed red blood cell, fresh frozen plasma and platelet ratio for the trauma transfusion pathway at a level 1 trauma centreEarly fixed-wing aircraft activation for major trauma in remote areasDevelopment of a national, multi-disciplinary trauma crisis resource management curriculum: results from the pilot courseThe management of blunt hepatic trauma in the age of angioembolization: a single centre experienceEarly predictors of in-hospital mortality in adult trauma patientsThe impact of open tibial fracture on health service utilization in the year preceding and following injuryA systematic review and meta-analysis of the efficacy of red blood cell transfusion in the trauma populationSources of support for paramedics managing work-related stress in a Canadian EMS service responding to multisystem trauma patientsAnalysis of prehospital treatment of pain in the multisystem trauma patient at a community level 2 trauma centreIncreased mortality associated with placement of central lines during trauma resuscitationChronic pain after serious injury — identifying high risk patientsEpidemiology of in-hospital trauma deaths in a Brazilian university teaching hospitalIncreased suicidality following major trauma: a population-based studyDevelopment of a population-wide record linkage system to support trauma researchInduction of hmgb1 by increased gut permeability mediates acute lung injury in a hemorrhagic shock and resuscitation mouse modelPatients who sustain gunshot pelvic fractures are at increased risk for deep abscess formation: aggravated by rectal injuryAre we transfusing more with conservative management of isolated blunt splenic injury? A retrospective studyMotorcycle clothesline injury prevention: Experimental test of a protective deviceA prospective analysis of compliance with a massive transfusion protocol - activation alone is not enoughAn evaluation of diagnostic modalities in penetrating injuries to the cardiac box: Is there a role for routine echocardiography in the setting of negative pericardial FAST?Achievement of pediatric national quality indicators — an institutional report cardProcess mapping trauma care in 2 regional health authorities in British Columbia: a tool to assist trauma sys tem design and evaluationPatient safety checklist for emergency intubation: a systematic reviewA standardized flow sheet improves pediatric trauma documentationMassive transfusion in pediatric trauma: a 5-year retrospective reviewIs more better: Does a more intensive physiotherapy program result in accelerated recovery for trauma patients?Trauma care: not just for surgeons. Initial impact of implementing a dedicated multidisciplinary trauma team on severely injured patientsThe role of postmortem autopsy in modern trauma care: Do we still need them?Prototype cervical spine traction device for reduction stabilization and transport of nondistraction type cervical spine injuriesGoing beyond organ preservation: a 12-year review of the beneficial effects of a nonoperative management algorithm for splenic traumaAssessing the construct validity of a global disability measure in adult trauma registry patientsThe mactrauma TTL assessment tool: developing a novel tool for assessing performance of trauma traineesA quality improvement approach to developing a standardized reporting format of ct findings in blunt splenic injuriesOutcomes in geriatric trauma: what really mattersFresh whole blood is not better than component therapy (FFP:RBC) in hemorrhagic shock: a thromboelastometric study in a small animal modelFactors affecting mortality of chest trauma patients: a prospective studyLong-term pain prevalence and health related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomized controlled trialDescribing pain following trauma: predictors of persistent pain and pain prevalenceManagement strategies for hemorrhage due to pelvic trauma: a survey of Canadian general surgeonsMajor trauma follow-up clinic: Patient perception of recovery following severe traumaLost opportunities to enhance trauma practice: culture of interprofessional education and sharing among emergency staffPrehospital airway management in major trauma and traumatic brain injury by critical care paramedicsImproving patient selection for angiography and identifying risk of rebleeding after angioembolization in the nonoperative management of high grade splenic injuriesFactors predicting the need for angioembolization in solid organ injuryProthrombin complex concentrates use in traumatic brain injury patients on oral anticoagulants is effective despite underutilizationThe right treatment at the right time in the right place: early results and associations from the introduction of an all-inclusive provincial trauma care systemA multicentre study of patient experiences with acute and postacute injury carePopulation burden of major trauma: Has introduction of an organized trauma system made a difference?Long-term functional and return to work outcomes following blunt major trauma in Victoria, AustraliaSurgical dilemma in major burns victim: heterotopic ossification of the tempromandibular jointWhich radiological modality to choose in a unique penetrating neck injury: a differing opinionThe Advanced Trauma Life Support (ATLS) program in CanadaThe Rural Trauma Team Development Course (RTTDC) in Pakistan: Is there a role?Novel deployment of BC mobile medical unit for coverage of BMX world cup sporting eventIncidence and prevalence of intra-abdominal hypertension and abdominal compartment syndrome in critically ill adults: a systematic review and meta-analysisRisk factors for intra-abdominal hypertension and abdominal compartment syndrome in critically ill or injured adults: a systematic review and meta-analysisA comparison of quality improvement practices at adult and pediatric trauma centresInternational trauma centre survey to evaluate content validity, usability and feasibility of quality indicatorsLong-term functional recovery following decompressive craniectomy for severe traumatic brain injuryMorbidity and mortality associated with free falls from a height among teenage patients: a 5-year review from a level 1 trauma centreA comparison of adverse events between trauma patients and general surgery patients in a level 1 trauma centreProcoagulation, anticoagulation and fibrinolysis in severely bleeding trauma patients: a laboratorial characterization of the early trauma coagulopathyThe use of mobile technology to facilitate surveillance and improve injury outcome in sport and physical activityIntegrated knowledge translation for injury quality improvement: a partnership between researchers and knowledge usersThe impact of a prevention project in trauma with young and their learningIntraosseus vascular access in adult trauma patients: a systematic reviewThematic analysis of patient reported experiences with acute and post-acute injury careAn evaluation of a world health organization trauma care checklist quality improvement pilot programProspective validation of the modified pediatric trauma triage toolThe 16-year evolution of a Canadian level 1 trauma centre: growing up, growing out, and the impact of a booming economyA 20-year review of trauma related literature: What have we done and where are we going?Management of traumatic flail chest: a systematic review of the literatureOperative versus nonoperative management of flail chestEmergency department performance of a clinically indicated and technically successful emergency department thoracotomy and pericardiotomy with minimal equipment in a New Zealand institution without specialized surgical backupBritish Columbia’s mobile medical unit — an emergency health care support resourceRoutine versus ad hoc screening for acute stress: Who would benefit and what are the opportunities for trauma care?A geographical analysis of the Early Development Instrument (EDI) and childhood injuryDevelopment of a pediatric spinal cord injury nursing course“Kids die in driveways” — an injury prevention campaignEpidemiology of traumatic spine injuries in childrenA collaborative approach to reducing injuries in New Brunswick: acute care and injury preventionImpact of changes to a provincial field trauma triage tool in New BrunswickEnsuring quality of field trauma triage in New BrunswickBenefits of a provincial trauma transfer referral system: beyond the numbersThe field trauma triage landscape in New BrunswickImpact of the Rural Trauma Team Development Course (RTTDC) on trauma transfer intervals in a provincial, inclusive trauma systemTrauma and stress: a critical dynamics study of burnout in trauma centre healthcare professionalsUltrasound-guided pediatric forearm fracture reduction with sedation in the emergency departmentBlock first, opiates later? The use of the fascia iliaca block for patients with hip fractures in the emergency department: a systematic reviewRural trauma systems — demographic and survival analysis of remote traumas transferred from northern QuebecSimulation in trauma ultrasound trainingIncidence of clinically significant intra-abdominal injuries in stable blunt trauma patientsWake up: head injury management around the clockDamage control laparotomy for combat casualties in forward surgical facilitiesDetection of soft tissue foreign bodies by nurse practitioner performed ultrasoundAntihypertensive medications and walking devices are associated with falls from standingThe transfer process: perspectives of transferring physiciansDevelopment of a rodent model for the study of abdominal compartment syndromeClinical efficacy of routine repeat head computed tomography in pediatric traumatic brain injuryEarly warning scores (EWS) in trauma: assessing the “effectiveness” of interventions by a rural ground transport service in the interior of British ColumbiaAccuracy of trauma patient transfer documentation in BCPostoperative echocardiogram after penetrating cardiac injuries: a retrospective studyLoss to follow-up in trauma studies comparing operative methods: a systematic reviewWhat matters where and to whom: a survey of experts on the Canadian pediatric trauma systemA quality initiative to enhance pain management for trauma patients: baseline attitudes of practitionersComparison of rotational thromboelastometry (ROTEM) values in massive and nonmassive transfusion patientsMild traumatic brain injury defined by GCS: Is it really mild?The CMAC videolaryngosocpe is superior to the glidescope for the intubation of trauma patients: a prospective analysisInjury patterns and outcome of urban versus suburban major traumaA cost-effective, readily accessible technique for progressive abdominal closureEvolution and impact of the use of pan-CT scan in a tertiary urban trauma centre: a 4-year auditAdditional and repeated CT scan in interfacilities trauma transfers: room for standardizationPediatric trauma in situ simulation facilitates identification and resolution of system issuesHospital code orange plan: there’s an app for thatDiaphragmatic rupture from blunt trauma: an NTDB studyEarly closure of open abdomen using component separation techniqueSurgical fixation versus nonoperative management of flail chest: a meta-analysisIntegration of intraoperative angiography as part of damage control surgery in major traumaMass casualty preparedness of regional trauma systems: recommendations for an evaluative frameworkDiagnostic peritoneal aspirate: An obsolete diagnostic modality?Blunt hollow viscus injury: the frequency and consequences of delayed diagnosis in the era of selective nonoperative managementEnding “double jeopardy:” the diagnostic impact of cardiac ultrasound and chest radiography on operative sequencing in penetrating thoracoabdominal traumaAre trauma patients with hyperfibrinolysis diagnosed by rotem salvageable?The risk of cardiac injury after penetrating thoracic trauma: Which is the better predictor, hemodynamic status or pericardial window?The online Concussion Awareness Training Toolkit for health practitioners (CATT): a new resource for recognizing, treating, and managing concussionThe prevention of concussion and brain injury in child and youth team sportsRandomized controlled trial of an early rehabilitation intervention to improve return to work Rates following road traumaPhone call follow-upPericardiocentesis in trauma: a systematic review." Canadian Journal of Surgery 56, no. 2 Suppl (April 2013): S1—S42. http://dx.doi.org/10.1503/cjs.005813.

Повний текст джерела

Стилі APA, Harvard, Vancouver, ISO та ін.

31

Thyagarajan, Braghadheeswar, Shil Patel, Natalie Swergold, Sayee Sundar Alagusundaramoorthy, Isha Verma, Thomas Baker, and Margaret Eng. "Abstract 37: Measure of Appropriateness in the Placement of Intravenacaval Filters Among Guidelines From Major Medical Societies." Arteriosclerosis, Thrombosis, and Vascular Biology 36, suppl_1 (May 2016). http://dx.doi.org/10.1161/atvb.36.suppl_1.37.

Повний текст джерела

Анотація:

Objective: With healthcare focusing towards quality based healthcare it has created significant interest among physicians in measuring and defining appropriateness in the treatment of medical conditions. We compared the indications for which the Intravenacaval (IVC) filter was placed in our hospital with the current guidelines by three of the major medical societies the American Heart Association (AHA), American College of Chest Physicians (ACCP) and Society for Interventional Radiology (SIR) to compare the measure of appropriateness in the placement of IVC filters among the guidelines Methods: We conducted a retrospective review of all charts with the ICD 9 code for placement of IVC filter from January, 2010 to January, 2015. Each patient chart was reviewed for patient demographics, complications and indications which were compared with the guidelines as defined by AHA, ACCP and SIR Results: During the 5 years, 592 patients underwent the procedure which included 233 men and 359 women who had a mean age of 67.2 +/- 17.4. 75.8% filters were inserted by vascular surgery and 24.2% filters were inserted by interventional radiology. 1.8% of the patients had some form of complication either during insertion or retrieval. On comparing the indications, we found that 35.5%(AHA), 30.9%(ACCP), 35.5%(SIR) were appropriate. While 4.4%(AHA), 4.4%(ACCP), 47.4%(SIR) were relatively appropriate and 60.1%(AHA), 64.7%(ACCP), 17.1%(SIR) were not appropriate. Commonly used indications not defined clearly included prophylaxis for bariatric surgery (14.4%) and high risk for fall (11%). Statistical analysis with the Chi-square test showed there was no statistical difference between AHA and ACCP (p =0.243), while statistical difference was present between AHA and SIR (p <0.001) and ACCP and SIR (p < 0.001) Conclusion: This study demonstrates that there are significant differences between the guidelines from major medical societies for the placement of IVC filter which leads to compelling discrepancies amongst physicians in their decision for the placement of IVC filters

Стилі APA, Harvard, Vancouver, ISO та ін.

32

Mackay, Ried. "Tlacoqualli in Monequi "The Center Good"." Voices in Bioethics 8 (October 27, 2022). http://dx.doi.org/10.52214/vib.v8i.10151.

Повний текст джерела

Анотація:

Photo by Andrew James on Unsplash INTRODUCTION Since its inception, bioethics has focused on Western conceptions of ethics and science. This has provided a strong foundation to build bioethics as a field and discipline. However, it has largely failed to consider non-Western systems of ethics and science like Indigenous American thought frameworks. This has important implications for the treatment of Indigenous Americans in healthcare settings, something that I have considered as a mixed Indigenous American researcher of sociology, global health and bioethics. While there has been recognition of other thought frameworks impacting bioethics, these have largely focused on differences among religions and their adherents. While religious frameworks are important, bioethics must also recognize, learn, and implement different cultural frameworks. Bioethics cannot simply recognize these non-Western frameworks; it must also legitimately incorporate them as frameworks. Non-Western conceptions have too often been used in a secondary status or as a historical outlier or curiosity which leads to failure in integrating non-Western frameworks to their full extent and benefit. BACKGROUND Indigenous American philosophy has strong foundations throughout North and South America[1] that can provide a base for developing Indigenous-focused bioethics. While Indigenous Americans cannot be considered a monolith, there are similarities across Indigenous cultures in their approach to reality—developing Indigenous bioethics will necessarily incorporate these shared philosophies.[2] These similarities are present in the US philosophical tradition of pragmatism. Pragmatism arises from the Indigenous pragmatism which values interacting with other beings and the environment, plurality of thought, connections to the community, and growth from the other three dimensions.[3] This shared pragmatism centers the actions of individuals as the defining feature of maintaining balance in all scenarios of socializing and work—achieving the “center good.” [4] Tlacoqualli in Monequi is a Mexica (Aztec) saying that translates to the “center good is required” and means “middle way of being” or consistently managing imbalances and obligations to achieve a long-term balance. For example, indulging in excesses requires the opposite to follow: making do with less for a period or balancing receiving with giving.[5] The actions of individuals must maintain the balance, which simultaneously encourages self-responsibility and responsibility to the community.[6] Additionally, the individual is not judged only by their actions but also by their omissions—failure to act either unintentionally or intentionally—and judged on the morality of their decision as if they had acted.[7] There have been calls for developing Indigenous bioethics,[8] including analyses of important distinctions between Western and Indigenous ethical approaches to health care such as how Indigenous patients understand core bioethical concepts like autonomy and non-maleficence.[9] These differences in thought impact all aspects of Indigenous health care and how providers approach fundamental tasks like revealing diagnoses or encouraging surgeries.[10] Indigenous ethics place great value on individual decisions made in the context of community input. Failing to appreciate this cultural difference can prevent an Indigenous patient from maintaining the center good and therefore violate a fundamental aspect of being.[11] Providers must also understand the nuances of religion and Indigenous ethics. While many Indigenous people adhere to elements of Christianity or other religious philosophies, many Indigenous people still maintain traditional cosmovisions.[12] These cosmovisions—ways that Indigenous communities understand life, earth, the universe and its moral constructs—demand adherence not to a supreme ethereal deity but to Indigenous pragmatism and, therefore, the “center good” so that an individual can live a happy and healthy life. Failing to adhere to the cosmovisions results in the decay of that person, and even their community, on physical, emotional, and spiritual levels.[13] ANALYSIS Previous work on Indigenous bioethics has referred to Indigenous philosophies in a secondary way. This placement of Indigenous ethics onto a second tier still demands that Indigenous patients adhere to dominant Western ethical discourses. Indigenous pragmatism calls for a plurality of thought and method. This means that Western ethics can apply in the treatment of Indigenous patients, but that Indigenous ethics must be on an equal plane or elevated above Western ethics in the treatment of Indigenous patients. The Indian Health Service (IHS) in the US provides an example. This system is treaty-obligated to provide health care to Indigenous Americans, the only racialized group in the US to have federal government-provided healthcare. However, many providers in the expansive IHS system operate from a Western ethic. This viewpoint leads to negative interactions and miscommunications.[14] It also adds to the persistent racism and ethnocentrism documented in the IHS by the US Commission on Civil Rights.[15] Multiple paths to achieving Indigenous health equity exist. However, a vital component is engaging a specific Indigenous ethic based on Indigenous philosophies rather than merely referencing them. Indigenous patients of the IHS can receive more culturally sensitive and competent care if they are engaged on a cultural level. A brief hypothetical to illustrate: a non-Indigenous IHS physician requests an ethics consult to convince a patient they need surgery; the provider views this as non-maleficence (a way to avoid harm to the patient) and is frustrated with the involvement of the patient’s family and close friends in the patient’s decision to delay the surgery; the doctor views the involvement of other people as a violation of the patient’s autonomy. The Indigenous patient views the physician’s continued insistence as offensive and becomes frustrated that their decision to delay is not respected. The physician and the patient view both autonomy and non-maleficence differently. The Indigenous patient views autonomy as a fundamental interaction between oneself and one’s communities, not as a purely individual choice. The patient also does not view the physician’s actions as doing no harm, as the violation of the Indigenous worldview is causing distress to the patient. In this hypothetical, the physician could alleviate the distress by understanding the patient’s ethics. The decision to delay the operation based on community feedback is an autonomous decision of the patient who does not view the delay as a harm but as a positive, since they are patiently exploring their options and ensuring that their community is equally comfortable with the decision. In this case, the insistence that the patient violate their Indigenous pragmatism causes the harm and violation of autonomy. l. Progress and Considerations Bioethics has made important strides toward cultural competency and many programs train students in medical disciplines. While there have been significant improvements in cultural competency training and recognition, programs still do not adequately consider care of Indigenous patients,[16] and they do not sufficiently consider the complexities of Indigenous decision making. US laws privilege the Western conception of autonomy and the accompanying understanding of individualism.[17] However, these laws and frameworks do not sufficiently consider complex Indigenous nuances and communal social structures. While Indigenous patients, or their proxy, will be the one to sign off on a decision, the process still centers a Western understanding of individualism, autonomy, and body[18] that constrains Indigenous patients and often demands violation of their balanced “center good.” Resolving this conflict conceptually and in practice is not easy and will continue to require patience and the necessary involvement of Indigenous communities, bioethicists, and practitioners. CONCLUSION Indigenous philosophies often oppose traditional Western ethics employed in US healthcare. The IHS provides care to Indigenous people and could employ and further develop the use of Indigenous pragmatism and ethics. An Indigenous patient that is treated based on Indigenous philosophies and ethics can receive care and consultations that incorporate their interactions and responsibilities to their families and communities and recognize that the Indigenous patient will have a plurality of thought systems and requests based in multiple cultural contexts that may seem foreign to non-Indigenous practitioners and ethicists. The center good here demands fully incorporating Indigenous philosophies and bioethics. Failing to maintain this center good and develop explicit Indigenous ethics for all Indigenous patients—inside and out of the IHS—only serves to continue the severe healthcare inequalities experienced by Indigenous communities. - [1] Léon-Portilla, Miguel. 1963. Aztec Thought and Culture: A Study of the Ancient Nahuatl Mind. Norman, OK: University of Oklahoma Press; Pratt, Scott L. 2002. Native Pragmatism: Rethinking the Roots of American Philosophy. Bloomington, IN: Indiana University Press. [2] Ellerby, Jonathan H., John McKenzie, Stanley McKay, Gilbert J. Gariépy, Joseph M. Kaufert. 2000. “Bioethics for clinicians: 18. Aboriginal cultures”. Canadian Medical Association Journal 163(7):845-850; Cordova, V.F. 2007. How It Is: The Native American Philosophy of V.F. Cordova. Tucson, AZ: University of Arizona Press. [3] Pratt 2002 [4] Dunbar-Ortiz, Roxanne. 2014. An Indigenous Peoples' History of the United States. Boston, MA: Beacon Press; Graeber, David and David Wengrow. 2021. The Dawn of Everything: A New History of Humanity. New York, NY: Farrar, Straus and Giroux. [5] Maffie, James. 2019. “Weaving the Good Life in a Living World: Reciprocity, Balance and Nepantla in Aztec Ethics” Science, Religion and Culture (https://dx.doi.org/10.17582/journal.src/2019.6.1.15.25). [6] Maffie, James. 2022. “Aztec Philosophy” Internet Encyclopedia of Philosophy. https://iep.utm.edu/aztec-philosophy/#H6 [7] Abarbanell, Linda and Marc D. Hauser. 2009. “Maya Morality: An exploration of permissible harms” Cognition 115(2010):207-224. [8] Ellerby et al. 2000; Abarbanell & Hauser 2009 [9] Kotalik, Jaro and Gerry Martin. 2016. “Aboriginal Health Care and Bioethics: A Reflection on the Teaching of the Seven Grandfathers”. The American Journal of Bioethics 16(5):38-43 (https://doi.org/10.1080/15265161.2016.1159749); Wescott, Siobhan and Beth Mittelstet. 2020. “Three Levels of Autonomy and One Long-Term Solution for Native American Health Care”. AMA Journal of Ethics 22(10):856-861 (https://doi.org/10.1001/amajethics.2020.856) [10] Ellerby et al. 2000 [11] Maffie 2022 [12] Leeming, Ben. 2013. “’Jade Water, Gunpowder Water’: Water Imagery in Nahuatl Descriptions of Heaven & Hell”. Presented at the American Society for Ethnohistory annual meeting. New Orleans, LA. (https://www.academia.edu/11810951/_Jade_Water_Gunpowder_Water_Water_Imagery_in_Nahuatl_Descriptions_of_Heaven_and_Hell). [13] Maffie 2022 [14] Gurr, Barbara. 2014. Reproductive Justice: The Politics of Health Care for Native American Women. New Brunswick, NJ: Rutgers University Press. [15] US Commission on Civil Rights. 2004. Broken Promises: Evaluating the Native American Health Care System. (https://www.usccr.gov/files/pubs/docs/nabroken.pdf). [16] Nortjé, Nico, Kristen Jones-Bonofiglio and Claudia R. Sotomayor. 2021. “Exploring values among three cultures from a global bioethics perspective”. Global Bioethics 32(1):1-14.; Winters, Alexandra. 2016. “Trespass to Culture: The Bioethics of Indigenous Populations’ Informed Consent in Mainstream Genetic Research Paradigms”. American Indian Law Review 41(1):231-251. [17] Norjé et al. 2021 [18] Winters 2016

Стилі APA, Harvard, Vancouver, ISO та ін.

33

Sagot, Adam J. "Advocacy Training in Residency and Addressing Needs in Child and Adolescent Psychiatry: A Review." JAACAP Connect 7, no. 3 (November 1, 2020). http://dx.doi.org/10.62414/001c.92372.

Повний текст джерела

Анотація:

The American Medical Association (AMA), in its Declaration of Professional Responsibility, states that all physicians must “advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”1 Increasingly, medical schools and graduate medical education (GME) programs are “adopting advocacy and service-learning curricula that include community resource identification and referral, screening for social determinants of health, and effective use of medical-legal partnerships and political engagement,” aimed to improve outcomes of physician-driven advocacy efforts.2

Стилі APA, Harvard, Vancouver, ISO та ін.

34

Black-Schaffer, W. Stephen, David J. Gross, Zakia Nouri, Aidan DeLisle, Michael Dill, Jason Y. Park, James M. Crawford, et al. "Re-evaluation of the methodology for estimating the U.S. specialty physician workforce." Health Affairs Scholar, March 19, 2024. http://dx.doi.org/10.1093/haschl/qxae033.

Повний текст джерела

Анотація:

Abstract Increasing pursuit of subspecialized training has quietly revolutionized physician training, but the potential impact on physician workforce estimates has not previously been recognized. The Physicians Specialty Data Reports of the Association of American Medical Colleges, derived from specialty designations in the American Medical Association Physician Professional Data (PDP), are the reference source for US physician workforce estimates; by 2020 the report for pathologists is an undercount of 39% when compared to the PDP. Most of the difference was due to omission of pathology subspecialty designations. The rest resulted from reliance on only the first of the AMA Physician Professional Data’s two specialty data fields. Placement of specialty designation in these two fields is sensitive to sequence of training and is thus affected by multiple or intercalated (between years of residency training) fellowships. Both these phenomena have become progressively more common and are not unique to pathology. Our findings demonstrate the need to update definitions and methodology underlying estimates of the US physician workforce for pathology and suggest a like need in other specialties affected by similar trends.

Стилі APA, Harvard, Vancouver, ISO та ін.

35

Winberg, Debra R., Matthew C. Baker, Xiaochu Hu, and Keith A. Horvath. "Who Participates in Value-Based Care Models? Physician Characteristics and Implications for Value-based Care." Health Affairs Scholar, July 16, 2024. http://dx.doi.org/10.1093/haschl/qxae087.

Повний текст джерела

Анотація:

Abstract Value-Based Care (VBC) payment models are becoming increasingly prevalent as alternatives to the traditional fee-for-service paradigm. This research quantifies the relationship between physician characteristics and participation in VBC payment models using the Association of American Medical Colleges’ 2022 National Sample Survey of Physicians. We specified logistic regressions using physician-level variables to assess associations with current and new participation in Accountable Care Organizations, Primary Care First (PCF) model, capitation, and bundled payments. Our results indicate that most respondents engaged in at least one VBC. Participation varied based on several characteristics, and physician specialty was highly predictive of overall participation. Compared to primary care physicians (PCPs), hospital-based physicians (OR=0.6, p<0.001), medical specialists (OR=0.5, p<0.001), psychiatrists (OR=0.4, p<0.001), and surgeons (OR=0.5, p<0.001) were less likely to participate in VBC models. Medical specialists and surgeons were less likely to participate in commercial capitation than PCPs while medical specialists and obstetricians/gynecologists were more likely to participate in certain bundles than PCPs. We suggest several policies to close the cross-specialty participation gap by including specialists and appealing to providers and patients.

Стилі APA, Harvard, Vancouver, ISO та ін.

36

Naito, Hiromichi, Tetsuya Yumoto, Takashi Yorifuji, Tsuyoshi Nojima, Hirotsugu Yamamoto, Taihei Yamada, Kohei Tsukahara, et al. "Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study." BMC Emergency Medicine 21, no. 1 (September 16, 2021). http://dx.doi.org/10.1186/s12873-021-00499-z.

Повний текст джерела

Анотація:

Abstract Background Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA. Methods A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age ≥ 16, at least one trauma with Abbreviated Injury Scale score (AIS) ≥ 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival. Results Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36–70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22–41), and median transport time was 11 min (IQR 6–17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%. Conclusion The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically.

Стилі APA, Harvard, Vancouver, ISO та ін.

37

Zwilling, Jana, Barbara Wise, Christine Pintz, Mary Beth Bigley, Brenda Douglass, Tracie W. Kirkland, Stefanie La Manna, et al. "U.S. Primary Care Provider Needs: An Analysis of Workforce Projections and Policy Implications." Policy, Politics, & Nursing Practice, August 21, 2023. http://dx.doi.org/10.1177/15271544231190606.

Повний текст джерела

Анотація:

The primary care (PC) physician workforce has consistently been projected as requiring additional numbers to meet the needs of the U.S. The Health Resources and Service Administration (HRSA) has reported the PC nurse practitioner (NP) workforce to be 90,000 NPs more than required to meet the PC needs of the U.S. With both clinician types contributing to the PC workforce in the country, it is difficult to understand such an oversupply of NPs with continued deficit in PC physicians. The purpose of this study was to investigate results and methods used for HRSAs current PC workforce projections and compare those with the same used for Bureau of Labor Statistics (BLS) and American Association of Medical Colleges (AAMC) projections. Methods included a review of technical documents, dashboards, and published reports. Interviews with subject matter experts were also completed. Projections were found to differ significantly, as did data and assumptions. Two of the three projections modeled physicians as the sole provider of PC. An integrated model gives the most comprehensive and accurate picture of PC workforce needs. The utilization of NPs as PC providers has been demonstrated to be safe and effective, with the potential to alleviate predicted shortages, improve patient care outcomes, reduce cost, and address PC inequities. Implications include improving workforce data, creating projections that mirror clinical integration in PC, adjusting workforce preparation funding, incentivizing interprofessional collaboration in research, addressing barriers to practice among non-physician providers, and leveraging growth in the NP workforce.

Стилі APA, Harvard, Vancouver, ISO та ін.

38

Strand, Gianna. "Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials." Voices in Bioethics 9 (March 27, 2023). http://dx.doi.org/10.52214/vib.v9i.11031.

Повний текст джерела

Анотація:

Photo 190773207 / Transplant Medicine © Victor Moussa | Dreamstime.com ABSTRACT Xenotransplant research offers hope to individuals waiting for vital organ transplants. Nascent first-in-human xenotransplantation research trials present unique ethical challenges which may translate into obligations for researchers and special considerations for institutional review boards (IRBs). Contextual vulnerability is an important consideration in reviewing proposed subject selection methods. Some recipients are uniquely prone to receiving an unfair offer to enroll in an experimental clinical trial when excluded from allograft waitlists due to psychosocial or compliance evaluations. These exclusions represent an allocational injustice. Enrolling research subjects subjectively excluded from allotransplantation into xenotransplant research is not a mechanism of fair access but rather an exploitation of an unjustly option-constrained vulnerable group by the clinical transplant system. Carefully considering contextual vulnerability can help researchers and IRBs clarify eligibility criteria for xenograft clinical trials. A requirement for simultaneous allograft co-listing can safeguard the interests of vulnerable potential subjects. INTRODUCTION In the United States, the supply of allogeneic, or human-derived, organs and tissues from living donors and cadavers available for transplant into critically ill individuals is inadequate.[i] Physicians refer only half of potentially eligible patients for transplant evaluation, and the clinical transplant team ultimately waitlists less than 30 percent.[ii] Waitlists are lengthy for those who make it through the evaluation process, and many individuals die while waiting for a transplant.[iii] In contrast to allogeneic transplants, xenotransplantation, from the prefix, xeno- meaning foreign, is the process of taking live organs or tissues from an animal for surgical placement into a human recipient. Xenografts are typically sourced from porcine animals (domestic pigs) or non-human primates (baboons) and range from simple tissues like corneas to complex vital organs like hearts, lungs, or kidneys. Scientists have explored xenotransplantation methods for decades, but research with vital organ xenotransplants has been in largely haphazard and non-controlled studies, which demonstrated only short-duration survival for recipients.[iv] Recent advances using gene modification and improved immunosuppression in single-patient attempts to transplant porcine organs into brain-dead human recipients have presented more realistic human-environment models; however, these modified xenografts have still functioned only for very short durations.[v] The limited bioethics discourse on xenotransplantation centers primarily on the ethical use of high-order animals and the risks of zoonotic infectious disease spread.[vi] Bioethics pays insufficient attention to the potential for exploitation of vulnerable individuals in need of a transplant amid growing interest in phase I clinical trials in living human subjects. Clinician-investigators in contemporary literature repeatedly recommend that these trials enroll subjects who are medically eligible for, but effectively excluded or outright denied access to, an allograft.[vii] The Food & Drug Administration (FDA) recommends xenotransplants be limited to subjects with serious or life-threatening diseases for whom adequately safe and effective alternative therapies are not available.[viii] The ethically salient difference between the investigator and the regulatory recommendations is why alternatives are not available to potential subjects: because transplant centers have subjectively denied access or because there is a clinical contraindication that proves prohibitively risky. In a notable single-patient emergency use authorization, physician-investigators offered a genetically modified porcine heart to a living male recipient after denying him access to the waitlist for a human-donor heart, citing a history of non-compliance.[ix] This case suggests that a person denied access to a transplant waitlist due to subjective compliance criteria is an appropriate research subject. The physician-investigators failed to acknowledge how offering a xenotransplant to a contextually vulnerable subject is potentially unfair. Contextual vulnerability is a specific feature of a research environment that increases a subject’s risk of harm. Bioethics discourse must address this vulnerability within the transplant research environment. This paper describes the current transplant system’s use of subjective evaluation criteria, particularly psychosocial support and compliance. Subjective evaluation criteria perpetuate discriminatory medical biases rather than advance the transplant system’s goal of additional life-years gained. Researchers designing controlled human subject trials and institutional review boards (IRBs) reviewing and approving proposed protocols must consider how disparate waitlisting practices unjustly preclude some patients from a fair opportunity to access an allograft and impacts their participation in research. It is unethical for physician-investigators to intentionally take advantage of this vulnerability, creating an exploitative and unethical transaction.[x] Protocol inclusion criteria requiring proof of simultaneous allograft listing is a feasible procedural safeguard to protect research subjects’ interests. I. Injustices in Organ Allocation Solid organ allocation systems are varied but aim for equity and efficiency in granting individuals with similar claims a fair opportunity to access the scarce resource. Allocation decisions attempt to maximize the common good of additional life-years gained.[xi] The federal oversight of allograft allocation in the US uses objective clinical metrics like blood type, immune compatibility, body size, and geographic distance to match organs to recipients to increase both graft and patient survival.[xii] Transplant centers additionally use their own evaluations to waitlist patients. Although variation exists between transplant center criteria across more objective measurements, such as lab values and concurrent diseases, significant inconsistencies arise in how they incorporate subjective factors like compliance with medical recommendations, psychosocial support, and intellectual disability into the review process.[xiii] Only 7 percent of renal transplant programs use formal criteria for subjective psychosocial assessments, while no pediatric solid organ transplant programs use formal, explicit, or uniform review to assess developmental delays and psychosocial support.[xiv] Failing to establish uniform definitions and inconsistently applying evaluation criteria in the review of potential transplant candidates introduce bias into listing practices.[xv] The center they present to and the variable evaluative criteria the center uses may discount an individual’s claim to a fair opportunity to access a scarce resource. Labeling a patient non-compliant can preclude both a referral to and placement on a waitlist for potentially suitable recipients. Compliance considerations presuppose that graft longevity will be jeopardized by an individual’s failure to adhere to pre- and post-transplant regimens. It is necessary to distinguish individuals who are intentionally non-adherent to treatment regimens and demonstrate willful disregard for medical recommendations from those who are involuntarily non-adherent due to barriers that limit full participation in care plans. The former would not be offered a spot on the waitlist for an allograft, nor would investigators offer them a spot in a xenotransplantation research study. Significant and repeated refusals to participate in treatment plans would confound the ability of researchers to collect necessary data and perform the safety monitoring required by early-phase clinical trials. Enrolling subjects who are medically eligible for a traditional transplant but denied access requires a population that is suitably compliant to participate in a clinical trial reliably and safely yet judged not worthy of receipt of a standard allograft during the evaluation process. The latter population is most disadvantaged by compliance judgments and unsubstantiated outcome predictions. Multi-center research studies have found that moderate non-adherence to immunosuppression regimens is not directly associated with poor kidney transplant outcomes.[xvi] Nor are intellectual and developmental disabilities, conditions for which transplant centers may categorically refuse evaluation, clear indicators of an individual’s ability to comply with treatment regimens.[xvii] Large cohort studies of both pediatric kidney and liver transplant recipients found no correlation between intellectual disability and graft or patient survival.[xviii] Rather, it is the perpetuation of medical biases and quality-of-life judgments that presumptively label specific populations poor transplant candidates or label their support systems insufficient, notwithstanding data demonstrating their ability to achieve successful transplant outcomes.[xix] Variability in compliance assessments and psychosocial support criteria allows medical biases to persist and disproportionately impedes waitlist access to patients from underserved populations.[xx] Low-income Medicaid patients are 2.6 times more likely to be labelled non-compliant as privately insured patients.[xxi] Additionally, the medical records of Black patients are 2.5 times more likely to contain negative descriptors like non-compliant, non-adherent, aggressive, unpleasant, and hysterical than those of white patients.[xxii] The higher prevalence of stigmatizing, compliance-based language in the medical records of minority, economically disadvantaged, and disabled persons decreases the likelihood that they will be recommended for a transplant, referred for an evaluation, placed on a waiting list, or ultimately receive a transplant.[xxiii] These populations are at heightened risk of being used in ethically inappropriate ways by xenograft research that capitalizes on this precluded access. II. Defining Vulnerability Subjective evaluation criteria in allograft waitlisting disproportionately impact some populations. This precluded access to waitlists increases their vulnerability to experience harm in experimental xenotransplant research. Fair subject selection requires the development of specific and appropriate inclusion and exclusion criteria designed to address and minimize known subject vulnerabilities.[xxiv] This process begins with physician-investigators designing research trials and IRB review of proposed trials in which some or all potential subjects are vulnerable.[xxv] The literature has no consensus on defining vulnerability in the clinical or research setting.[xxvi] Prominent guidelines such as the Common Rule and the Declaration of Helsinki focus on a categorical, consent-based approach to assessing vulnerability. The capacity to provide freely given consent is a necessary prerequisite for ethical human subject research. Still, consent alone is insufficient to establish ethical permissibility or assure that a research transaction is fair.[xxvii] Harm can occur even with informed consent if it results from coercion, undue influence, or exploitation.[xxviii] Subjects have limited ability to avoid exploitation and act as an autonomous moral agents under such circumstances. Categorical assessments label groups whose members share salient features, such as prisoners or children, as vulnerable. This shared characteristic may compromise their capacity for free consent and autonomous ability to protect their interests. Although widely used, broad categorizations create monolithic views of populations but lack clarity as to why a particular feature makes one vulnerable or what a given characteristic decidedly renders one vulnerable to.[xxix] Individuals broadly vulnerable in society, such as the severely economically disadvantaged or incarcerated, are not necessarily vulnerable as research subjects in a given proposed trial.[xxx] Categorical vulnerability is insufficient to recognize that research-related harm is specific to a particular subject potentially participating in a given protocol at a definite time and place. III. Assessing for Contextual Vulnerability Ensuring ethical consent, therefore, requires more than an accounting of capacity, competency, and freedom from coercion. This requires looking beyond voluntariness to ask whether the research offer is fair. Contextual vulnerability recognizes and addresses how some subjects are at a heightened risk of being used in ethically inappropriate ways due to research-specific situations and environments.[xxxi] Contextual vulnerability derives from a specific feature of the research environment that increases a subject’s risk of harm rather than an intrinsic categorical condition of that subject. Accounting for contextual vulnerabilities is necessary because it is ethically unsound for a competent subject to give voluntary consent to an offer that is nonetheless unfair or exploitative.[xxxii] Potential subjects excluded from accessing an allograft are contextually vulnerable in a research environment that may view their diminished range of choice as an opportunity for experimental research enrollment. Proposals to exploit or take advantage of this vulnerability places these individuals at a heightened risk of research-related harm. IV. Exploitative Transactions in Xenotransplant Research In the landmark single-patient case in Maryland, a genetically modified porcine heart was offered to the subject only because he was denied access to the allograft waitlist due to a history of noncompliance with a recommended medical regimen.[xxxiii] Physician-investigators did not define how they evaluated compliance, nor did they elaborate on how this claim demonstrated the subject’s clear and convincing contraindication to receive a conventional cardiac allograft. The subject was presented with a so-called Hobson’s choice, in which there is the illusion of free choice but ultimately there is no real choice as only one outcome, the acceptance of the experimental xenograft, is permitted; access to other choices, such as pursuing standard of care waitlisting, have been removed.[xxxiv] This case set a precedent for researchers and IRBs to view individuals denied access to conventional allografts as an appropriate subject population without acknowledgment of how this transaction is consensually exploitative. Consensual exploitation occurs when researchers intentionally and wrongfully take advantage of a subject’s vulnerability.[xxxv] In the cardiac xenotransplant case, the application of subjective evaluation criteria created a unique contextual vulnerability specific to transplant waitlist practices. Investigators took advantage of the subject’s diminished ability to access the heart transplant waitlist to obtain consent for the xenotransplant procedure. Researchers have no obligation to repair unjust conditions that they bear no responsibility for causing.[xxxvi] The wrongfulness in this case is how subjective compliance-based waitlisting criteria precluded the subject from accessing the heart transplant waitlist and denied him fair consideration in accessing the standard clinical option. Then, the transplantation team exploited this disadvantage they were morally responsible for creating. The subject agreed to the terms for an experimental and high-risk xenograft from a place of vulnerability due to the diminished range of choice specifically constructed by the policy and actions of the transplant center. The options offered by the physician-investigators to the patient were manipulated to promote the research system’s interests through the production of new scientific knowledge, not necessarily the subject’s conception of his own good.[xxxvii] V. Recommendation for Simultaneous Allograft Listing Ethical research design calls for assessments of which vulnerabilities and in which contexts researchers and IRBs ought to offer additional safeguards. Subjects should be clinically suitable to produce robust, reliable, and generalizable scientific knowledge and be presented with a fair research offer. Researchers and IRBs can achieve this through an inclusion criterion requiring that a subject has previously been placed on and maintains a spot on a waitlist for a conventional allograft. Investigators and IRBs must ensure that subjects are selected based on scientific rationale, not because they are easy to recruit due to a compromised or vulnerable position.[xxxviii] Evidence of simultaneous allograft listing would provide verification that a researcher expects a potential subject to survive the burdens of an experimental xenotransplant procedure. Individuals of advanced age or with severe life-limiting comorbidities separate from their end-stage organ failure are less likely to survive after receiving an allograft or a research xenograft. These subjects would not produce valuable data in service to the study’s endpoints or knowledge generalizable to broader patient populations. Requiring evidence of simultaneous allograft listing fulfills the ethical requirement that subjects who withdraw consent are not worse off than if they had not pursued research enrollment.[xxxix] If a subject withdraws consent before receiving a xenograft, their continued place on a waitlist ensures that their fair opportunity claim to an allograft has been maintained. Simultaneous allograft waitlisting excludes contextually vulnerable subjects clinically suitable to receive a graft but denied access to a waitlist. This inclusion criteria provides an additional safeguard against unfairly capitalizing on a subject’s marginalized status. Requiring simultaneous allograft listing will narrow the potential subject population to those clinically suitable and well situated to receive a fair opportunity to enroll in research: individuals listed for an allograft but significantly unlikely to receive or to benefit from that allograft. This potential subject population includes individuals with broadly reactive antibodies who are unlikely to match to a donor organ and individuals with anatomical contraindications who face prohibitive risks with standard allografts or bridging therapies.[xl] This subject population aligns with the FDA recommendation to enroll subjects for whom safe and effective alternatives are not available.[xli] These individuals have not had their claim to a fair opportunity transgressed by a subjective evaluation process, nor has their interest in accessing a scarce resource been unjustly discounted.[xlii] Neither the individual nor the transplant clinicians are responsible for creating a clinical or statistical disadvantage to receiving a standard allograft. An offer of research enrollment extended to this population has not been manipulated to favor one party over the other, but rather appropriately considers the interests of both parties.[xliii] Researchers have an interest in identifying subjects capable of producing scientifically valuable knowledge. Potential subjects have an interest in exploring alternatives to the high morbidity of a traditional allograft. This subject population retains the autonomous choice to pursue a standard-of-care allograft or to enroll in xenograft research. Having few treatment options available does not inexorably undermine the voluntariness of research consent or increase vulnerability.[xliv] The consent transaction is not exploitative or unfair because the transplant system is not responsible for creating this diminished range of choice. Simultaneous allograft listing represents an eligibility criterion that responds to and limits the products of subjective decisions from unjustly impacting trial enrollment. VI. Counterargument: Is Something Better Than Nothing? Some may argue that for medically exigent individuals in need of a transplant, any option to participate in research is better than no option. Autonomy and dignity, however, are not advanced when an inability to access the standard of care compels a subject’s decision to pursue experimental research. An offer of research enrollment that is unfair or exploitative remains unethical regardless of whether the subject stands to benefit. Nor should benefit be expected in early-phase research. The goals of phase I research are primarily to collect short-term safety, toxicity, dosing, and pharmacologic data, not to provide efficacious treatment.[xlv] Expanding access to experimental research trials cannot be conflated with fair access to equitable health care.[xlvi] Broadened access alone does not produce a more ethical research environment. Excluding contextually vulnerable subjects from research should not be the end goal, but rather a necessary interim to call attention to the need to redress biases and existing injustices in transplant access. Research that targets a population’s vulnerability serves to enable the continuation of unjust systems. CONCLUSION In summary, the urgent and significant clinical need for transplantable organs cannot undermine the requirements of ethical research design and conduct. Fair subject selection is a requirement of ethical clinical research.[xlvii] Potential subjects enrolled in upcoming xenograft research must be selected for their ability to answer the scientific objectives of a proposed study and must have the capacity to provide freely given informed consent within a fair research environment. Denying access to allotransplants for subjective psychosocial or compliance-based claims creates contextual vulnerability specific to transplant research that perpetuates the unfairness of the organ allocation system. Ethical research that produces valuable scientific knowledge cannot exploit the rights or interests of subjects in the process. A look beyond categorical vulnerability to contextual vulnerability highlights this currently overlooked area of exploitation. - [i] “Organ Donation Statistics,” Health Resources and Services Administration, accessed April 18, 2022, https://www.organdonor.gov/learn/organ-donation-statistics. [ii] Schold, J.D. et al., “Barriers to Evaluation and Wait Listing for Kidney Transplantation,” Clinical Journal of the American Society of Nephrology 6, no. 7 (2011): 1760-67. [iii] Abouna, G.M. “Ethical Issues in Organ Transplantation,” Medical Principles and Practice 12, no. 1 (2003): 54-69. [iv] Anderson, M. “Xenotransplantation: A Bioethical Evaluation,” Journal of Medical Ethics 32, no. 4 (2006): 205-8. [v] Lambert, J. “What Does the First Successful Test of a Pig-to-Human Kidney Transplant Mean?,” ScienceNews, October 22, 2021, https://www.sciencenews.org/article/xenotransplantation-pig-human-kidney-transplant.; Koplon, S. “Xenotransplantation: What It Is, Why It Matters and Where It Is Going,” UAB News, February 17, 2022, https://www.uabmedicine.org/-/xenotransplantation-what-it-is-why-it-matters-and-where-it-is-going. [vi] Anderson, supra; Daar, A.S. “Ethics of Xenotransplantation: Animal Issues, Consent, and Likely Transformation of Transplant Ethics,” World Journal of Surgery 21, no. 9 (1997): 975-82.; Kim, M.K., et al., “The International Xenotransplantation Association Consensus Statement on Conditions for Undertaking Clinical Trials of Xenocorneal Transplantation,” Xenotransplantation 21, no. 5 (2014): 420-30. [vii] Abouna, supra; Pierson, R.N., et al., “Pig-to-Human Heart Transplantation: Who Goes First?,” American Journal of Transplantation 20, no. 10 (2020): 2669-74. [viii] Food and Drug Administration, Source Animal, Product, Preclinical, and Clinical Issues Concerning the Use of Xenotransplantation Products in Humans (Silver Spring, MD, 2016), 43, https://www.fda.gov/media/102126/download. [ix] Wang, W., et al., “First Pig-to-Human Heart Transplantation,” Innovation (Camb) 3, no. 2 (2022): 100223. [x] Carse, A.L. and Little, M.O. “Exploitation and the Enterprise of Medical Research,” in Exploitation and Developing Countries, ed. J. S. Hawkins and E. J. Emanuel (Princeton, NJ: Princeton University Press, 2008), 206-45. [xi] Halpern, S.D. and Goldberg, D.“Allocating Organs to Cognitively Impaired Patients,” New England Journal of Medicine 376, no. 4 (2017): 299-301. [xii] “How We Match Organs,” United Network for Organ Sharing, accessed April 18, 2022, https://unos.org/transplant/how-we-match-organs/. [xiii] UW Medicine Harborview Medical Center – UW Medical Center University of Washington Physicians, Selection Criteria: Kidney Transplant Recipient (Seattle, WA, 2019), 1-3, https://www.uwmedicine.org/sites/stevie/files/2020-11/UW-Medicine-Kidney-Selection-Criteria-UH2701.pdf; Penn Medicine, Kidney Transplant Selection Criteria (Philadelphia, PA: Hospital of the University of Pennsylvania), 1-2. https://www.pennmedicine.org/media/documents/instructions/transplant/kidney_transplant_selection_criteria.ashx. [xiv] Dudzinski, D.M. “Shifting to Other Justice Issues: Examining Listing Practices,” American Journal of Bioethics 4, no. 4 (2004): 35-37.; Richards, C.T., et al., “Use of Neurodevelopmental Delay in Pediatric Solid Organ Transplant Listing Decisions: Inconsistencies in Standards Across Major Pediatric Transplant Centers,” Pediatric Transplant 13, no. 7 (2009): 843-50. [xv] Dudzinski, supra. [xvi] Israni, A.K., et al., “Electronically Measured Adherence to Immunosuppressive Medications and Kidney Function after Deceased Donor Kidney Transplantation,” Clinical Transplantation 25, no. 2 (2011): 124-31. [xvii] National Council on Disability, Organ Transplant Discrimination against People with Disabilities (Washington, DC, 2019), 25-35, https://ncd.gov/sites/default/files/NCD_Organ_Transplant_508.pdf.; Halpern and Goldberg, supra. [xviii] Wightman, A., et al., “Prevalence and Outcomes of Renal Transplantation in Children with Intellectual Disability,” Pediatric Transplantation 18, no. 7 (2014): 714-19.; Wightman, A., et al., “Prevalence and Outcomes of Liver Transplantation in Children with Intellectual Disability,” Journal of Pediatric Gastroenterology and Nutrition 62, no. 6 (2016): 808-12. [xix] Richards et al., supra; Godown, J., et al., “Heart Transplantation in Children with Down Syndrome,” Journal of the American Heart Association 11, no. 10 (2022): e024883. [xx] Silverman, H. and Odonkor, P.N. “Reevaluating the Ethical Issues in Porcine-to-Human Heart Xenotransplantation,” Hastings Center Report 52, no. 5 (2022): 32-42. [xxi] Sun, M., et al., “Negative Patient Descriptors: Documenting Racial Bias in the Electronic Health Record,” Health Affairs 41, no. 2 (2022): 203-11. [xxii] Ibid. [xxiii] Dudzinski, supra; Garg, P.P., et al., “Reducing Racial Disparities in Transplant Activation: Whom Should We Target?,” American Journal of Kidney Diseases 37, no. 5 (2001): 921-31. [xxiv] Emanuel, E.J., et al., “What Makes Clinical Research Ethical?,” JAMA 283, no. 20 (2000): 2701-11. [xxv] 45 C.F.R. 46.111(b). [xxvi] Hurst, S.A. “Vulnerability in Research and Health Care; Describing the Elephant in the Room?,” Bioethics 22, no. 4 (2008): 191-202. [xxvii] The Nuremberg Code, Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law 2, no. 10: 181-2 (Washington, DC: U.S. Government Printing Office, 1949); Kipnis, K. “Vulnerability in Research Subjects: A Bioethical Taxonomy. Ethical and Policy Issues in Research Involving Human Participants.,” in Ethical and Policy Issues in Research Involving Human Participants, (Bethesda, MD: National Bioethics Advisory Commission, August 2001), G1-G13. [xxviii] Dickert, N. and Grady, C. “Incentives for Research Participants,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 386-96. [xxix] Gordon, B.G. “Vulnerability in Research: Basic Ethical Concepts and General Approach to Review,” Ochsner Journal 20, no. 1 (2020): 34-38. [xxx] Kipnis, supra. [xxxi] Hurst, supra. [xxxii] Lamkin, M. and Elliott, C. “Avoiding Exploitation in Phase I Clinical Trials: More Than (Un)Just Compensation,” Journal of Law, Medicine & Ethics 46, no. 1 (2018): 52-63.; Jansen, L.A. “A Closer Look at the Bad Deal Trial: Beyond Clinical Equipoise,” Hastings Center Report 35, no. 5 (2005): 29-36. [xxxiii] Wang et al., supra; Silverman and Odonkor, supra. [xxxiv] Silverman and Odonkor, supra. [xxxv] Carse and Little, supra. [xxxvi] Wertheimer, A. “Exploitation in Clinical Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 201-210. [xxxvii] Brock, D.W. “Philosophical Justifications of Informed Consent in Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 606-612. [xxxviii] Council for International Organizations of Medical Sciences, International Ethical Guidelines for Health-Related Research Involving Humans (Geneva: World Health Organization, 2016), https://cioms.ch/wp-content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf. [xxxix] Ibid. [xl] Pierson et al., supra. [xli] Food and Drug Administration, supra. [xlii] Hurst, supra. [xliii] Kipnis, supra. [xliv] Hawkins, J.S. and Emanuel, E.J. “Introduction: Why Exploitation?,” in Exploitation and Developing Countries, ed. J. S. Hawkins and E. J. Emanuel (Princeton, NJ: Princeton Universiy Pres, 2008), 1-20. [xlv] Muglia, J.J. and DiGiovanna, J.J. “Phase 1 Clinical Trials,” Journal of Cutaneous Medicine and Surgery 2, no. 4 (1998): 236-41. [xlvi] Dresser, R. “The Role of Patient Advocates and Public Representatives in Research,” in The Oxford Textbook of Clinical Research Ethics, ed. E. J. Emanuel et al. (Oxford University Press, 2008), 231-41. [xlvii] MacKay, D. and Saylor, K.W. “Four Faces of Fair Subject Selection,” The American Journal of Bioethics 20, no. 2 (2020): 5-19.

Стилі APA, Harvard, Vancouver, ISO та ін.

39

Kim, Min Hee, and Xiaoling Xiang. "Hospitalization Trajectories in Home- and Community-Based Services Recipients: The Influence of Physician and Social Care Density." Journals of Gerontology: Series B, November 10, 2020. http://dx.doi.org/10.1093/geronb/gbaa199.

Повний текст джерела

Анотація:

Abstract Objectives Repeated hospitalizations among older adults receiving Home- and Community-Based Services (HCBS) may indicate unmet medical and social needs. This study examined all-cause hospitalization trajectories and the association between area-level resource density for medical and social care and the trajectory group membership. Methods The study participants included 11,223 adults aged 60 years or older who were enrolled in public HCBS programs in Michigan between 2008 and 2012. Data sources included the Michigan interRAI-Home Care, Dartmouth Atlas of Health Care Data, the American Community Survey, and the County Business Patterns from the Census Bureau. The group-based trajectory modeling was used to identify trajectories of hospitalization over 15 months. Correlates of the trajectories were examined using multinomial logistic regression. Results Four distinct hospitalization trajectory groups emerged: “never” (43.1%)—individuals who were rarely hospitalized during the study period, “increasing” (19.9%)—individuals who experienced an increased risk of hospitalization, “decreasing” (21.6%)—individuals with a decreased risk, and “frequent” (15.8%)—individuals with frequent hospitalizations. Older adults living in areas with a higher number of social service organizations for older adults and persons with disability were less likely to be on the “frequent” trajectory relative to the “decreasing” trajectory. The density of primary care physicians was not associated with the trajectory group membership. Discussion Area-level social care resource density contributes to changes in 15-month hospitalization risks among older adult recipients of HCBS.

Стилі APA, Harvard, Vancouver, ISO та ін.

40

Sutherland, Mason, Carol Sanchez, Amanda Baroutjian, Aleeza Ali, Mark McKenney, and Adel Elkbuli. "Gender, Race, Age, Allopathic Degree, Board Score, and Research Experience Among Applicants Matching to General and Orthopedic Surgery Residencies, 2015-2019." American Surgeon, February 8, 2021, 000313482199198. http://dx.doi.org/10.1177/0003134821991982.

Повний текст джерела

Анотація:

Background Surgical fields are historically dominated by male physicians. Increasing the diversity of the physician workforce improves training and patient experiences. We aim to investigate any differences in qualifications and match rates between male and female applicants to general surgery (GS) and orthopedic surgery (OS) residencies in the United States. Methods A retrospective cohort analysis was performed utilizing the Association of American Medical Colleges data regarding Electronic Residency Application Service (ERAS) applicants and matched Accreditation Council for Graduate Medical Education (ACGME) residents into GS and OS residencies from 2015 to 2019. Descriptive statistics and independent sample T-tests were performed with significance defined as P < .05. Results 26 568 GS and 7076 OS ERAS applicants matched at a rate of 25.2% and 55.3%, respectively. Men and women matched into GS at rates of 23.0% and 29.2%, respectively. Men and women matched into OS at rates of 55.2% and 56.2%, respectively. Men aged ≥36 years matched into OS at a significantly higher rate than women aged years ≥36 (11.9% vs. 1.4%, P = .009). Female GS ERAS applicants and entering ACGME residents had a higher mean number of research experiences than male GS ERAS applicants (2.66 vs. 2.26, P < .001) and entering male GS ACGME residents (2.96 vs. 2.56, P = .008). Conclusions Male and female GS and OS applicants have similar qualifications. Women match into GS and OS at higher rates than men but comprise disproportionately lower numbers of applicants. Greater mentorship opportunities and recruitment of female applicants are needed to expand, diversify, and increase representation of women in surgery.

Стилі APA, Harvard, Vancouver, ISO та ін.

41

Faillace, Robert T., Richard B. Siegrist, Steven Duchensky, Lorraine Marut, Ilene Matza, Lucena Sarimento, Kathleen Cahill, Eileen Bogdanowitz, and Michele Sabatino. "Abstract 3524: Implementation of the American Heart Association Get With the Guidelines Heart Failure Program (GWTG-HF) Reduces Length of Stay and Decreases Cost for Hospitalized Heart Failure Patients at St. Joseph’s Regional Medical Center (SJRMC)." Circulation 116, suppl_16 (October 16, 2007). http://dx.doi.org/10.1161/circ.116.suppl_16.ii_798-a.

Повний текст джерела

Анотація:

Hospitalized heart failure patients (HF) may not consistently receive standards of care and hospitals frequently realize a financial loss in the care of HF patients. GWTG-HF makes it more likely to ensure optimal care, decrease direct cost and increase hospital profit in the management of HF patients. HYPOTHESIS: Utilization of GWTG-HF with a multi-disciplinary team would be associated with a consistent application of standards of care, shorter duration of hospitalization and less direct cost for hospitalized HF patients. METHODS: GWTG-HF was fully operational in 2006 with a multi-disciplinary team consisting of a Physician Champion, Advanced Practice Nurses (APNs), Case Managers and RNs. APNs utilized GWTG-HF at the point of service and worked collaboratively with attending physicians. We compared the average length of stay, total number of hospitalized days, patient revenue, total direct cost, contribution margin, and the profit/loss for hospitalized HF patients in 2005 to those in 2006. RESULTS: There were 773 cases of HF admissions in 2005 as compared to 781 in 2006. Overall compliance with GWTG-HF Core Measures in 2006 was 98% (HF-1 D/C Instructions 99%; HF-2 Left ventricular systolic (LVS) function evaluation 96%; HF-3 ACEI/ARB for LVS dysfunction 98%; HF-4 Smoking cessation advice 100%; Beta Blocker Use 95%). The average length of stay (LOS) in 2005 was 6.7 days as compared to 6.3 days in 2006 (p <0.02). The total number of hospital days in 2005 was 5,145 as compared to 4,880 in 2006 (p<0.02). Between 2005 and 2006 patient revenue increased by $279,847 (p<0.01), direct cost decreased by $348,014 (p<0.05), contribution margin increased by $627,861 (p=0.06) and the full cost profit margin increased by $309,460 (NS). CONCLUSION: Utilization of GWTG-HF at SJRMC is associated with a high compliance with standards of hospitalized HF care, decrease in average LOS, decrease in total number of hospital days and decrease in direct cost. Although not statistically significant, hospital contribution margin and profit increased for acutely decompensated HF patients.

Стилі APA, Harvard, Vancouver, ISO та ін.

42

Huang, Yu-Sheng, Wen-Chu Chiang, Patrick Chow-In Ko, Sot Shih-Hung Liu, Chien-Hao Lin, Kah-Meng Chong, Ming-Tai Cheng, et al. "Abstract 205: Termination of Resuscitation Rules for Traumatic Cardiopulmonary Arrest: Old Dogma, New Validation." Circulation 128, suppl_22 (November 26, 2013). http://dx.doi.org/10.1161/circ.128.suppl_22.a205.

Повний текст джерела

Анотація:

Introduction: Pre-hospital terminations of resuscitation (TOR) rules for traumatic cardiopulmonary arrest (TCPA) have been proposed by the National Association Emergency Medical Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACSCOT) for a decade. However, validation studies from United Kingdom and Australia produced conflicting results. This study aimed to evaluate the performance of TOR rules for TCPA in an Asian metropolitan area. Methods: We analyzed data from an Utstein registry system of adult patients with TCPA in Taipei to test the performance of the first guiding criteria of TOR for TCPA: blunt trauma patient found in asystole upon the arrival of emergency medical service (EMS) at the scene. Predictive outcome was in-hospital death. Test statistics including sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and decreased transport rate (DTR) were calculated. Results: From Jan 1, 2008 to Dec 31, 2009, there were 328 adult patients with TCPA. The mechanism was blunt trauma in 155 (47.3%), penetrating trauma in 106 (32.3%) and uncertain in 106 (32.3%), and mechanisms were 155 (47.3%), 106 (32.3%), and 67 (20.4%). The presenting rhythm was asystole in 54/155 (34.8%) of blunt trauma, 57/107(53.3%) of penetrating trauma, and 28/67 (41.8%) of uncertain mechanism. Overall survival rate of TCPA (to hospital discharge) were 11/328 (3.4%). For those with blunt trauma, only 4 survived to hospital discharge (2.6%). The test statistics of the first guiding criteria (i.e. patients with blunt trauma and asystole) and sensitivity analysis by categorizing uncertain mechanism as blunt trauma were presented in the Table. Conclusion: Application of the first rule of thumb proposed by NAEMSP and ACSCOT for adult patients with TCPA can accurately identify non-survivors (100% PPV and 100% specificity) and decrease unnecessary EMS transports (16.5%~25.0%) in an Asian Metropolitan area.

Стилі APA, Harvard, Vancouver, ISO та ін.

43

Gray, Bradley M., Jonathan L. Vandergrift, Jennifer P. Stevens, Rebecca S. Lipner, Furman S. McDonald, and Bruce E. Landon. "Associations of Internal Medicine Residency Milestone Ratings and Certification Examination Scores With Patient Outcomes." JAMA, May 6, 2024. http://dx.doi.org/10.1001/jama.2024.5268.

Повний текст джерела

Анотація:

ImportanceDespite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians’ milestone residency ratings or the American Board of Internal Medicine’s initial certification examination and their hospitalized patients’ outcomes is sparse.ObjectiveTo examine the association between physicians’ milestone ratings and certification examination scores and hospital outcomes for their patients.Design, Setting, and ParticipantsRetrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals.Main Outcomes and MeasuresPrimary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year.ExposuresCertification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly.ResultsAmong 455 120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, −5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, −13.0% to −3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, −13.0% to −5.7%; P &lt; .001). For 30-day mortality, this association was −3.5% (95% CI, −6.7% to −0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P &lt; .003) but was not associated with length of stay or 30-day readmission rates.Conclusions and RelevanceAmong newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.

Стилі APA, Harvard, Vancouver, ISO та ін.

44

Yu, Colburn. "Policies Affecting Pregnant Women with Substance Use Disorder." Voices in Bioethics 9 (April 22, 2023). http://dx.doi.org/10.52214/vib.v9i.10723.

Повний текст джерела

Анотація:

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

Стилі APA, Harvard, Vancouver, ISO та ін.

45

Sanchez Alonso, Jason. "Undue Burden the Medical School Application Process Places on Low-Income Latinos." Voices in Bioethics 9 (November 7, 2023). http://dx.doi.org/10.52214/vib.v9i.10166.

Повний текст джерела

Анотація:

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

Стилі APA, Harvard, Vancouver, ISO та ін.

46

Lewis, Cara. "Protecting Confidentiality in the Digital Ecosystem of Humanitarian Aid." Voices in Bioethics 10 (March 12, 2024). http://dx.doi.org/10.52214/vib.v10i.12505.

Повний текст джерела

Анотація:

Photo by AbsolutVision on Unsplash INTRODUCTION Social media, news headlines, and podcasts implicitly and explicitly remind us of the digital misinformation maelstrom we navigate every day to understand the truth of current events. Misinformation feeds off the topics that impact our lives and draw our attention – war, health, politics, identity, fear, and empathy. Misinformation has a digital reach faster and wider than true information based on its nature of novelty and emotional instigation.[1] It draws from data leakages, twists the truth, incites emotional responses, and can undermine real efforts to protect and aid vulnerable communities. Many of the places and events targeted by misinformation are sites of humanitarian crises such as Gaza, Yamen, and Ukraine among many others. Humanitarian groups conceived to provide relief to vulnerable communities are susceptible to personal harm and impeded aid because the organizational structure is not equipped for misinformation and data security breaches. While propaganda and misinformation did not emerge in the contemporary, their scope, speed, and impact have exponentially increased as the world’s use of digital media for communication developed. The current state of misinformation and data leakages are threats to humanitarian efforts, especially the vital and nuanced task of humanitarian medical aid that now simultaneously relies on the digital information ecosystem. ANALYSIS Humanitarian efforts center on the four main principles of humanity, neutrality, impartiality, and operational independence. The United Nations Refugee Agency specifies that ‘humanity’ refers to addressing human suffering wherever it is found to ensure health and respect, ‘neutrality’ is to not engage in political, racial, religious, or ideological controversies, ‘impartiality’ is to provide aid based on need alone without bias and priority, and ‘operational independence’ is to conduct aid autonomous from agendas or actors in sectors such as political, economic, or military.[2] Medecins Sans Frontieres explicitly states neutrality, impartiality, independence, bearing witness, and accountability in their code of principles. Their statement on medical ethics is much more vague. It aims to “carry out our work with respect for the rules of medical ethics, in particular the duty to provide care without causing harm to individuals or groups. We respect patients’ autonomy, patient confidentiality, and their right to informed consent.”[3] Confidentiality is mentioned, but in the nondescript sense that could refer to confidentiality outlined in any number of medical ethics contexts. Three most commonly referred to ethical codes in Western medicine are the Declaration of Helsinki, the Belmont Report, and the Code of the American Medical Association (AMA). The Declaration of Helsinki places confidentiality in the context of research and was written pre-digital age in the 1960s.[4] The Belmont Report does not mention confidentiality or patient privacy in its summation of medical ethics from 1978.[5] Lastly, the AMA’s Code of Medical Principles upholds that physicians “shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.”[6] This AMA principle was adopted in 1957 and revised in 2001, still before the onset of widely accessible digital media. These three medical ethics codes are the standard of Western medicine, and yet they are decades obsolete when facing the harm of digital misinformation and data leakages. Humanitarian aid organizations cannot afford to rely on outdated medical ethical codes amid digital misinformation and data leakages. Medical humanitarian relief groups such as Medecins Sans Frontiers, the International Medical Corps, the WHO Global Health and Peace Initiative, and the International Committee of the Red Cross, rely on the medical ethics defined in the aforementioned guides in addition to their humanitarian foundation. These codes, while useful, were written prior to the digital age. And, as our methods of communication, medical delivery, and global action have evolved and digitized, the ethics guiding medical practice should be updated to reflect this dramatic change. Humanitarian medical organizations need the digital ecosystem to store metadata for medical services such as patient history, blood type, metrics on locations in need of aid, missing person searches, and funding. The levels of data vulnerable to misconstruction and hacking exist on the personal and organizational levels. Individual providers and the organizational body should prioritize confidentiality. Thus humanitarian medical ethics should adapt to the reality of the digital age to not endanger the populations receiving aid and to not propagate harm. Misinformation and data leakage can lead to microtargeting, defamation, provider endangerment, and other harms preventing medical service. The European Data Protection Supervisor details how the personal information collected by organizations, such as medical, can be stolen or misconstrued to affect microtargeting, placing individuals in the direct path of echo chambers, digital tracking, and manipulation.[7] The International Broadcasting Trust released a report in 2018 detailing the extent to which misinformation was impacting the humanitarian aid groups it broadcasts to.[8] For example, the report shared that rumors spread by right-wing political groups in 2017 falsely circulated that humanitarian groups in the Mediterranean were collaborating with child trafficking rings.[9] After causing defamation, the right-wing group sent a boat to block and detain the humanitarian group’s search and rescue boat. This was one incident among many where providers and patients were put in harm’s way through misinformation and the misuse of location data. Other disinformation campaigns can be carried out by governments as well; in Syria and Ukraine, the Russian government has been specifically targeting Red ross and White Helmets.[10] Beneficial medical services cannot be delivered if providers and patients are targeted. In January of 2022, the International Association of the Red Cross was hacked. Approximately 515,000 vulnerable persons’ data was leaked and became inaccessible to the IARC providers.[11] If an organization cannot protect access to its digital ecosystem, humanitarian medical aid efforts can be rendered ineffective. Additionally, misinformation and breached data cause the less immediate but more widely impactful harm of distrust. Stakeholders and funding sources can withdraw from supporting medical humanitarian aid organizations. Beneficial medical services cannot be offered if there is no monetary backing. Providers and patients also have their own digital devices and means of communication which can lead to sensitive information being shared online or with non-neutral parties. If a patient cannot trust their provider or the organization a provider acts in the name of, medical services can be refused. Beneficial medical service cannot be conducted if the trust of the patient is compromised by humanitarian groups failing to prioritize patient confidentiality. Confidentiality should be prioritized in humanitarian medical aid to safeguard against the extended harms of data leakage, misinformation, and malintent. Some critiques may postulate that due to the uniqueness of each community aided by medical humanitarian organizations, over-standardization from rigid ethical codes may occur, that standardization can lead to inflexibility with communities and render aid strategies ineffective. However, the reality is that ethical frameworks make sure that individual actors are not monolithic – they allow for collaboration and joint work. The WHO Global Health and Peace Initiative’s recent adoption of conflict sensitivity, along with other organizations’ additions of similar language, ensure that there is a feedback loop incorporated into the ethical code to mitigate unintended harm. Thus, ethical codes are helping providers to respond in unprecedented situations with consciousness to harm propagation. In events of limited time and of crisis, comprehensive ethical codes are especially beneficial because we rely on habits and pre-established information banks. CONCLUSION Humanitarian medical ethics should include a specific guide for confidentiality. Without forethought and the integration of traditional and digital confidentiality as a main tenant, medical humanitarian organizations will continue to act retrospectively. Trust in stakeholder-provider-patient relationships will continue to disintegrate. The current status quo of medical ethics in the humanitarian aid sector poses multiple risks for providers and patients whereas adopting stronger confidentiality language is a tangible step towards the protection of vulnerable communities from the harms of digital misinformation and data leakage. - [1] Vosoughi, Soroush, Deb Roy, and Sinan Aral. “The Spread of True and False News Online.” Science 359, no. 6380 (2018): 1146–51. https://doi.org/10.1126/science.aap9559. [2] “Conflict Sensitivity and the Centrality of Protection.” The Global Portection Cluster , March 2022. https://www.globalprotectioncluster.org/sites/default/files/2023-03/220318_gpc_-_conflict_sens.pdf. [3] “Our Charter and Principles.” MEDECINS SANS FRONTIERES - MIDDLE EAST. Accessed December 24, 2023. https://www.msf-me.org/about-us/principles/our-charter-and-principles#:~:text=We%20give%20priority%20to%20those,of%20governments%20or%20warring%20parties.&text=The%20principles%20of%20impartiality%20and%20neutrality%20are%20not%20synonymous%20with%20silence. [4] “WMA - The World Medical Association-WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects.” The World Medical Association. Accessed December 24, 2023. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/. [5] Office for Human Research Protections (OHRP). “ The Belmont Report.” United States Department of Health and Human Services , September 27, 2022. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html. [6] American Medical Association . “The Code .” AMA principles of Medical Ethics. Accessed December 24, 2023. https://code-medical-ethics.ama-assn.org/principles. [7] “EDPS Opinion on Online Manipulation and Personal Data .” European Data Protection Supervisor. Accessed December 24, 2023. https://edps.europa.eu/sites/edp/files/publication/18-03-19_online_manipulation_en.pdf. [8] Robin. “Faking It: Fake News and How It Impacts on the Charity Sector.” International Broadcasting Trust, March 13, 2020. https://www.ibt.org.uk/reports/faking-it/. [9] Reed, B. “Charities Colluding with Traffickers? Fake News.” The Guardian, February 15, 2018. https://www.theguardian.com/global-development/2018/feb/15/charities-aid-agencies-fake-news-says-report. [10] Sant, Shannon Van. “Russian Propaganda Is Targeting Aid Workers.” Foreign Policy, August 1, 2022. https://foreignpolicy.com/2022/08/01/russia-disinformation-ukraine-syria-humanitarian-aid-workers/ . [11] International Committee of the Red Cross. “Hacking the Data of the World’s Most Vulnerable Is an Outrage.” International Committee of the Red Cross, October 27, 2022. https://www.icrc.org/en/document/hacking-data-outrage.

Стилі APA, Harvard, Vancouver, ISO та ін.

47

Riegler, Jacob. "Comparative Ethics of Modern Payment Models." Voices in Bioethics 9 (January 13, 2023). http://dx.doi.org/10.52214/vib.v9i.10310.

Повний текст джерела

Анотація:

Photo by Marek Studzinski on Unsplash ABSTRACT Payment models directly impact the way patients experience care. Historically, payment model innovations have been examined mostly from economic, organizational, and public health lenses. Financial incentives exist in all healthcare systems, whether a socialized, private or public insurance, or single payer system. This article examines the alignment of current predominant payment models of fee-for-service, capitation, and value-based payments with patient care ethics. The volume-based incentive of fee-for-service is misaligned with patient care, while capitation is a relatively neutral and highly modifiable model. Value-based payments offer a unique benefit in improving patient agency and have a larger benefit of cost control. However, no model adequately addresses health disparities, and a larger consideration for justice is needed by payment model designers when considering incentives. In consideration of related values, bioethics must expand the discourse around patient care ethics to cover patient interactions with the health system and market forces outside the clinical context. INTRODUCTION Healthcare payment models have always been controversial. Discussions about healthcare payment models broadly include economic, ethical, and medical realms. The “simple” act of one party paying for health care creates interactions between the payer, the provider, and the patient. Payments are based on an agreed-upon price between the paying party and the provider. While in most industries, at the level of retail delivery, the direct customer pays for the item received, in healthcare, the system is more complex. Deciding what metrics to base healthcare prices on has become arduous. Whether organizations should charge a patient for healthcare in nations where it is considered a human right is a subject of debate. This ethical debate over providing care is combined with the theoretical framework of how to price and pay for healthcare. This paper examines the ethics of various approaches to paying for care. Outside of the controversial notion of patients financing their care, existing payment models always involve some entity other than the patient paying for the bulk of the care – whether in a socialized system, single payer, or public or private insurance system. In these systems, an implicit financial incentive to provide care based on payment criteria arises.[1] Depending on the nature of the payment, the financial incentive may align with, be neutral toward, or misalign with a patient’s best interest and goals of care. These payments create market forces in capitalistic or single payer healthcare models and drive organizational behavior in nationalized models.[2] We can see the organizational and marketplace adaptations to predominant volume-based payment models in the United States in the form of shorter visits, unnecessary care or increased volume of care, and medical determination of which care is provided based on coverage. Fee-for-service has incentivized higher patient volume over quality time with patients, leading to 10- to 25-minute patient visits.[3] Payments based on any metric implicitly direct patient care by moving provider action toward the metric the payment is based on, regardless of intent or conscious effort.[4] For example, when the paying body financially rewards hospitals for shorter inpatient stays, then the average length of stay will decrease.[5] Payment for care has numerous, widespread effects on how patients experience care and even the quality of care they receive, creating ethical and economic issues. Oddly, from a strictly financial perspective, patients are secondary consumers of their care in most healthcare systems. With this, providers have a financial responsibility to the paying body to act within the bounds of payment incentives (specifically, the paying body, such as an insurance company, is assured that the patient gets the care that is paid for based usually on pre-agreed terms) and an ethical and duty-based responsibility to the patient for patient care. As an example of misaligned interests, there is a clear financial incentive to deny prior authorization for a medication that is an expensive yet otherwise appropriate alternative for a patient’s condition. This could result in equal treatment, perhaps a generic version even, or an alternative that the provider and patient would not have chosen otherwise. It could result in the patient being deprived of a choice. l. Patient Care Ethics and Payment Using the four principles of bioethics, the tenets of ethics for patient care, the payment systems have clear effects on patient autonomy and agency, and may conflict with beneficence, non-maleficence, and justice.[6]The tension that providers experience in navigating payers while fulfilling their patient responsibility causes ethical dilemmas. Volume-based reimbursement schemes prioritize efficiency, regardless of these major bioethical principles. To truly evaluate a payment model, we need not vaguely consider the supposed moral intentions of a model – we need to evaluate the theoretical incentive design as it pertains to the tenets of bioethics. I propose a novel model for viewing incentives with a bioethical framework. The motivation for viewing how the system design for payment models use incentives under a bioethical lens is summarized below. a. Payments, by nature, create active and passive organizational incentives. b. Incentives affect organizational and provider behavior, regardless of intent. c. Changed behavior in response to a financial incentive directly and implicitly impacts the tenets of bioethics. d. For payment models to be considered ethical, they must align organizational incentives with patient care goals and ethics. The argument that incentives should not exist in healthcare because they foster competition and, therefore, cause disparities is acknowledged.[7] However, the argument against incentives ignores the reality of healthcare, especially in the United States, where the most progressive recommendations still retain a paying agency. Therefore, the focus in this paper concerns the existing payment models. The alignment of predominant payment models—including fee-for-service, capitation or mixed models, and value-based payments —with patient care ethics is difficult. This paper argues that the value-based payment model is the most appropriately aligned model when considering health disparities, the Rawlsian difference principle, and distributive justice. ll. Payment Models and Patient Care Ethics Alignment Payment models are highly varied. As it currently stands, the most widely used model globally is fee-for-service, a volume-based model in which insurance companies pay physicians and organizations for performed actions based on evaluations such as relative value units. Relative value units consider physician work, practice expense, service rendered, and professional liability.[8] Later models, like capitation, were enacted to control costs. Simply put, purely capitated payments consist of flat-term payments for patient care that do not change based on services rendered.[9] Within the past decade, value-based payments, which pay physicians based on patient value, as defined by outcomes divided by costs, became popular.[10] There are other approaches to paying for patient care, such as health savings accounts or direct primary care (patients directly pay physicians without insurance).[11] While these are assuredly interesting areas of study, the financial incentives mimic fee-for-service, in which physicians and organizations receive payments based on direct services rendered and will not be discussed further in this article. lll. Fee-For-Service Fee-for-service is the main payment model worldwide.[12] It has played a large role in shaping the structural nature of healthcare, particularly in the United States.[13] Fee-for-service, although declining, is still pervasive in the US health system and has created market forces that indirectly affect the geographic distribution of care, with an obvious volume-based market force.[14] Even with the advent of alternative payment models, fee-for-service remains the primary mode of physician compensation by percentage in primary care in the US.[15] Fee-for-service’s financial and organizational incentives are based on the number of patients seen and services rendered. The World Health Organization stated in its 2010 Health System Financing report that this model likely leads to care overprovision, inefficiency, and upwardly spiraling costs.[16] The pervasive volume-based incentive in fee-for-service misaligns with patient care goals as patient care is not its primary goal. This rudimentary payment system attempts to finance health care as if it were any other good or industry. But more care is not necessarily better care, and fee-for-service leads to higher patient bills, higher system costs, and largely inefficient and unnecessary treatment schemes.[17] Tummalapalli, et al. found that capitated models had lower visit frequency and fewer interventional actions with no difference in outcomes compared to fee-for-service models. Care overprovision—in services rendered—and upwardly spiraling costs are not in the best interest of patients, violating beneficence at the population level. The misalignment of incentives is at the root of the problem. As a rudimentary payment system, fee-for-service does not have patient care in mind, nor has beneficence as its goal. To evaluate fee-for-service from its own goals, the question here should not center around whether this model is in the best interest of patients. Instead, it should focus on the principle of non-maleficence. Can we truly say that upwardly spiraling healthcare costs do not harm patients? In the US, fee-for-service has largely negative social effects on burdens in minority populations, enhancing disparity.[18] The system is arguably unjust, violating the principle of justice. Disadvantaged groups bear a disproportionally large brunt of the deleterious effects of fee-for-service.[19] With the wastefulness, the inefficiency, the failure to align with patient goals, and the injustice, it becomes clear that fee-for-service does not align with patient care ethics because of organizational and financial incentives. lV. Capitation and Mixed Payment Models Pure capitation is a less common model than fee-for-service. The maximum effectiveness of this model is generally achieved with some combination of fee-for-service or value-based payment modifiers.[20] Both in principle and practice, capping payments for a term or service period inherently controls costs by setting a payment “cap.” From a theoretical perspective, the issue here is clear – there are minimal incentives in pure capitation to provide more care. In some cases, this can lead to care underprovision.[21] This neglect is a problem: whether intended, there are generally fewer visits and interventional approaches to care in pure capitation models.[22] Some view the care under-provision as a disservice to patients. However, the true practice of capitation is rarely without some combined incentive model for organizations or physician salary.[23] Adding fee-for-service incentives to capitation balances these issues while maintaining a discordant theoretical incentive compared to patient care. Value-based modifiers add a more aligned incentive for reasons described in the following section. The overall nature of capitation is not inherently aligned or misaligned with patient care, given that it is a highly moldable model, and therefore is neutral regarding its alignment with patient care ethics. V. Value-Based Payments Since their inception, value-based payments have become a widespread and popular payment model internationally.[24] The payment revolves around value, defined as patient outcomes divided by costs. The assumption in adopting such a model is that outcomes and costs can be readily measured, which is a challenge in implementing this model. However, aligning payments with patient value has spurred the adoption of more accurate cost accounting systems and the innovation of patient-reported outcome measures. While the full details of cost accounting are beyond the scope of this paper, Robert Kaplan is a proponent of using time-driven activity-based costing, an essential component in calculating value and an empirically more accurate accounting method than the other predominant forms in healthcare and fee-for-service payments.[25] While this is an accomplishment, perhaps the more ethically interesting innovation in value-based payments comes from measuring patient outcomes. These generally take form in two ways: objective measures and patient-reported measures. The objective measures include ideally controllable disease factors, such as hospital admissions or disease exacerbations in patients living with chronic obstructive pulmonary disease.[26] Such measures align payment incentives with quality and results, an important aspect of patient care but not an absolute placeholder for ethical measures. One of the largest critiques of value-based payments has always been that value cannot simply be measured with empirical data but must account for patient values.[27] The solution to such a critique is patient-reported outcome measures (PROMs), which factor patient values and lifestyle into the empirical payment calculation.[28] A study by Groeneveld et al. showed that PROMs were useful in evaluating the progression of stroke patients at several different time intervals.[29] Bernstein showed that PROMs give insight into the sociodemographic factors a patient may be experiencing, which can guide targeted interventions.[30] To providers, these may not sound like innovative clinical tools, but they resemble the everyday scoring systems and social work consultations seen in patient care. PROMs are an attempt to formally incorporate such items directly to payment. Value-based payments directly incentivize innovation, use of accurate costs and the consideration of patient values. However, there are valid critiques. This payment model has the potential to prioritize care for those who are healthy and more likely to achieve favorable outcomes. Adjustment for important social factors could worsen outcomes and undermine the model’s propensity to drive value for all patients.[31] Comparatively, value-based payments still incentivize a market force that is more in line with patient care ethics when contrasted with the other predominant forms of payment. This payment model has the theoretical advantage of spurring competitive forces to work toward a goal-like value while outcomes consider patient priorities and costs to be more accurate. From an ethical standpoint, the ideal value-based payment model addresses beneficence toward patients with some (but comparatively less) potential for harm and worsening of disparities. Safeguards can protect patients in this realm. Another main ethical advantage of value-based payments is that they add more patient marketplace agency by allowing patient desires and priorities to play a direct role in the payment process. This is a unique benefit that value-based payments have over fee-for-service and pure capitation, where the latter models are simply modicums for payment, not modicums for patient agency. Based on these comparative ethics, the value-based payment models are the most aligned payment model with patient care ethics but require safeguards. Vl. Limitations of Payment Models in Addressing Disparities and Distributive Justice The aforementioned payment models continually miss opportunities to explicitly incentivize care for underserved and at-risk populations. Studies have explicitly shown how fee-for-service can worsen care for minority groups. The greatest difference in care is seen in the chronically ill, the poor, and those with high burdens based on the social determinants of health.[32] While value-based payments have been touted as a potential route to incentivize care for these populations, comparative studies show that those of lower socioeconomic status experienced no benefit when using a value-based modifier.[33] Other scholars have pointed out that these payment models are both slower to roll out in low-resource areas and are more likely to have the unintended consequence of leading to lower funding in these areas.[34] Therefore, the disparity may be a lack of access to the model rather than a reflection of its capabilities. These valid critiques of worsening health disparities under all existing payment models show that such models are not a silver bullet for the health system and that they do not address other crucial issues in medicine, like equity. However, this is not to say that payment models cannot address social disadvantages and disparities. Value-based payments more ethically align payment-related incentives and spur more innovation. To this end, innovation must take place with consideration for distributive justice. The Rawlsian difference principle, or the notion that any systemic approach must maximize the improvement of the least advantaged groups, is essential when discussing payment models.[35] As it currently stands, value-based payments may incentivize procedural justice or a more just and equitable process once patients are in the healthcare system. Yet, none of them ensure a just distribution of care to those of low socioeconomic status. Future models must work towards incentivizing principles of distributive justice. While there have been many attempts to modify payments, those who design payment models clearly tend not to leverage financial benefits to help patients of low socioeconomic status. By leaving those least well-off in society out of the consideration, payment model designers contribute to systemic disparities, regardless of intent. All future designers of payment models must do more to improve incentive designs to work for these patients, not against them. Vll. How Should We Ethically View Incentive Design? The public and those in charge of medical policy must realize the importance of market forces beyond efficiency. Payment incentives should align with patient well-being, autonomy, access to care for underserved populations, and market efficiency. While some of these factors will be more pertinent than others depending on which health system is under discussion, we need ethical principles for patients on a system level that prioritize the patient's interaction with the health system outside of purely clinical scenarios. CONCLUSION Payment models remain a powerful tool for any health system that pays providers or organizations. The simple act of payment creates both direct and indirect financial incentives. These incentives create market forces that affect how patients experience their care, directly impacting autonomy, beneficence, non-maleficence, and justice. As it currently stands, the predominant payment model of fee-for-service does not align with patient care ethics. While follow-up models to fee-for-service, such as capitation, aimed to simply control costs, neither explicitly intended to give patients marketplace agency or improve patient care ethics. The overall alignment of capitation and patient care ethics remained relatively neutral. Newer innovations such as value-based payments have a much stronger stated purpose of aligning payment with positive outcomes and lower costs, where outcomes have patient-defined criteria and costs are more accurate. Value-based payments create a comparatively more aligned model than fee-for-service or capitation. Yet no payment model fully addresses the tenet of justice, and the Rawlsian difference principle must be employed here to ensure that those of lowest socioeconomic status or the most disadvantaged are not worse off than before the implementation of a new payment model. As a system, healthcare should strive for the best possible outcomes for all patients, necessitating an integrated approach to social factors. - [1] Porter M. What is Value in Healthcare? N Engl J Med. 2010;363(26):2477-2482. [2] Kontopantelis E, Reeves D, Valderas JM, Campbell S, Doran T. Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: A longitudinal observational study. BMJ Qual Saf. 2013;22(1):53-64. doi:10.1136/bmjqs-2012-001033 [3] Linzer M, Bitton A, Tu SP, Plews-Ogan M, Horowitz KR, Schwartz MD. The End of the 15–20 Minute Primary Care Visit. J Gen Intern Med. 2015;30(11):1584-1586. doi:10.1007/s11606-015-3341-3 [4] Gupta R, Gupta S. The effect of explicit financial incentives on physician behavior. Arch Intern Med. 2002;162(5):612-613. doi:10.1001/archinte.162.5.612; Rosenthal M. How will paying for performance affect patient care? AMA Ethics. 2006;8(3):162-165. [5] Wang Y, Ding Y, Park E, Hunte G. Do Financial Incentives Change Length-of-stay Performance in Emergency Departments? A Retrospective Study of the Pay-for-performance Program in Metro Vancouver. Acad Emerg Med. 2019;26(8):856-866. doi:10.1111/ACEM.13635 [6] Beauchamp T, Childress J. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019. [7] Groenewoud AS, Westert GP, Kremer JAM. Value based competition in health care’s ethical drawbacks and the need for a values-driven approach. BMC Health Serv Res. 2019;19(1):1-6. doi:10.1186/s12913-019-4081-6 [8] Katz S, Melmed G. How relative value units undervalue the cognitive physician visit: A focus on inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2016;12(4):240-244.; Cattel D, Eijkenaar F. Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review. Medical Care Research and Review. 2020;77(6):511-537. doi:10.1177/1077558719856775 [9] Tummalapalli SL, Estrella MM, Jannat-Khah DP, Keyhani S, Ibrahim S. Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis. BMC Health Serv Res. 2022;22(1):1-12. doi:10.1186/s12913-021-07313-3; Emanuel EJ, Mostashari F, Navathe AS. Designing a Successful Primary Care Physician Capitation Model. JAMA - Journal of the American Medical Association. 2021;325(20):2043-2044. doi:10.1001/jama.2021.5133 [10] Porter M. 2477-2482. [11] Kofman M. HSAs: A Great Tax Shelter for Wealthy, Healthy People but Little Help to the Uninsured, Underinsured, And People with Medical Needs. AMA Ethics. 2005;7(7):522-524.; Eskew PM, Klink K. Direct primary care: Practice distribution and cost across the nation. Journal of the American Board of Family Medicine. 2015;28(6):793-801. doi:10.3122/jabfm.2015.06.140337 [12] Cattel D, Eijkenaar F. 511-537 [13] Linzer M, Bitton A, Tu SP, Plews-Ogan M, Horowitz KR, Schwartz MD. 1584-1586. [14] Lurie N. The role of market forces in US health care. New England Journal of Medicine. 2020;383(15):1401-1404. [15] Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL. Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems. JAMA Health Forum. 2022;3(1):e214634. doi:10.1001/jamahealthforum.2021.4634 [16] WHO. Health System Financing Country Profile. 2013. [17] Tummalapalli SL, Estrella MM, Jannat-Khah DP, Keyhani S, Ibrahim S. 1-12. [18] Hudson D, Sacks T, Irani K, Asher A. The price of the ticket: Health costs of upward mobility among African Americans. Int J Environ Res Public Health. 2020;17(4):1-18. doi:10.3390/ijerph17041179 [19] Ibid. [20] Tummalapalli SL, Estrella MM, Jannat-Khah DP, Keyhani S, Ibrahim S. 1-12.; Emanuel EJ, Mostashari F, Navathe AS. 2043-2044; Brosig-Koch J, Hennig-Schmidt H, Kairies N, Wiesen D. How to improve patient care? An analysis of capitation, fee-for-service, and mixed payment schemes for physicians. RUHR Economic Papers. Published online 2013:1-36. doi:10.1080/00185860009596559 [21] Emanuel EJ, Mostashari F, Navathe AS. 2043-2044; Brosig-Koch J, Hennig-Schmidt H, Kairies N, Wiesen D. 1-36. [22] Ibid. [23] Emanuel EJ, Mostashari F, Navathe AS. 2043-2044.; Reid RO, Tom AK, Ross RM, Duffy EL, Damberg CL. e214634. [24] Porter M. 2477-2482.; Teisberg E, Wallace S, O’Hara S. Defining and Implementing Value-Based Health Care: A Strategic Framework. Academic Medicine. 2020;95(5):682-685. doi:10.1097/ACM.0000000000003122 [25] Kaplan RS, Anderson SR. Time-Driven Activity-Based Costing Robert S. Kaplan and Steven R. Anderson November 2003. Harv Bus Rev. 2003;82(November):131-138.; Akhavan S, Ward L, Bozic KJ. Time-driven Activity-based Costing More Accurately Reflects Costs in Arthroplasty Surgery. Clin Orthop Relat Res. 2016;474(1):8-15. doi:10.1007/s11999-015-4214-0 [26] Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest. 2016;150(4):916-926. doi:10.1016/j.chest.2016.05.002 [27] Lynn J, McKethan A, Jha AK. Value-based payments require valuing what matters to patients. JAMA - Journal of the American Medical Association. 2015;314(14):1445-1446. doi:10.1001/jama.2015.8909 [28] Groeneveld IF, Goossens PH, van Meijeren-Pont W. Value-Based Stroke Rehabilitation: Feasibility and Results of Patient-Reported Outcome Measures in the First Year After Stroke. Journal of Stroke and Cerebrovascular Diseases. 2019;28(2):499-512. doi:10.1016/j.jstrokecerebrovasdis.2018.10.033; Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. Do Patient Sociodemographic Factors Impact the PROMIS Scores Meeting the Patient-Acceptable Symptom State at the Initial Point of Care in Orthopaedic Foot and Ankle Patients? Clin Orthop Relat Res. 2019;477(11):2555-2565. doi:10.1097/CORR.0000000000000866 [29] Groeneveld IF, Goossens PH, van Meijeren-Pont W, et al. 499-512. [30] Bernstein DN, Mayo K, Baumhauer JF, Dasilva C, Fear K, Houck JR. 2555-2565 [31] Tran L. Social Risk Adjustment in Health Care Performance Measures. JAMA Netw Open. 2020;3(6). doi: doi:10.1001/jamanetworkopen.2020.8020 [32] Webster NJ. Medicare and Racial Disparities in Health: Fee-for-Service versus Managed Care. Vol 28. Elsevier; 2010. doi:10.1108/S0275-4959(2010)0000028005 [33] Roberts ET, Zaslavsky AM, Mcwilliams JM. The value-based payment modifier: Program outcomes and implications for disparities. Ann Intern Med. 2018;168(4):255-265. doi:10.7326/M17-1740 [34] Bazzoli GJ, Thompson MP, Waters TM. Medicare Payment Penalties and Safety Net Hospital Profitability: Minimal Impact on These Vulnerable Hospitals. Health Serv Res. 2018;53(5):3495-3506. doi:10.1111/1475-6773.12833 [35] Ekmekci PE, Arda B. Enhancing John Rawls’s Theory of Justice to Cover Health and Social Determinants of Health. Acta Bioeth. 2015;21(2):227-236. doi:10.4067/S1726-569X2015000200009

Стилі APA, Harvard, Vancouver, ISO та ін.

48

Cajiao, Ximena. "Colombia and Medical Tourism." Voices in Bioethics 9 (December 5, 2023). http://dx.doi.org/10.52214/vib.v9i.11941.

Повний текст джерела

Анотація:

Photo ID 131102170 © Geckophotos | Dreamstime.com INTRODUCTION Medical tourism should contribute to developing a more robust healthcare system that acts in the best interests of patients and ensures equal access to healthcare. This paper examines medical tourism in Colombia and argues that developing a system that aligns with bioethical principles is necessary. People traveling for care should have access to the Ministry of Health rather than only the Ministry of Industry and Tourism, emphasizing their purpose as patients seeking medical procedures or treatments rather than tourists engaging in leisure activities. Additionally, in the interest of justice, Colombian patients should benefit from the revenue derived from medical tourism. It is crucial to recognize that both patients traveling for care and people in the destination country can derive benefits from medical tourism. The Colombian government can protect the rights and well-being of patients seeking care and ensure that any benefits are distributed fairly among Colombian citizens. I. Background Medical tourism refers to people traveling to foreign countries to obtain health care.[1] Many individuals from high-income countries seek health care in less developed countries to take advantage of the lower costs. Destination countries are increasingly showing interest in becoming medical tourism hubs due to the significant financial potential of this multi-billion dollar industry. The global medical tourism market is projected to reach $207.9 billion by 2027.[2] This growth not only generates income but also creates employment opportunities and business prospects for local residents in sectors such as tourism, pharmaceuticals, and infrastructure. By establishing themselves as medical tourism destinations, countries can stimulate economic development and enhance their healthcare structure. Colombia is among the fastest-growing medical tourism destinations in the world. It has become a popular destination for medical tourists due to its advanced healthcare infrastructure, biotechnology, and highly skilled physicians who cater to international patients at affordable prices.[3] The healthcare entities in Colombia offer a wide range of medical procedures, including cardiovascular, bariatric, orthopedics, cosmetic surgery, dental care, and fertility treatments. [4] The Colombian government has actively promoted medical tourism to position the country as a destination for world-class medical services.[5] Through strategic economic policies, effective regulation, and digital marketing, medical tourism has emerged as a significant contributor to Colombia’s income. The Colombian Ministry of Industry and Tourism, which regulates medical tourism in Colombia, forecasts at least 2.8 million health tourists and a revenue of at least $6.3 billion by 2032.[6] Colombia intends to have medical tourism play a significant role in its economy. However, ethical issues exist. The Colombia Ministry of Industry and Tourism is more involved in medical tourism than the Ministry of Health is. Additionally, the government has not been held accountable for the shortcomings in the medical tourism industry. There should be an organization advocating for the rights and well-being of medical tourists. Furthermore, using public funds to attract international patients may divert funds from local communities. Last, the negative impacts of medical tourism on Colombian patients deserve attention. This paper aims to explore these ethical issues from two perspectives: that of medical tourists and that of Colombian citizens. I argue that the benefits of medical tourism outweigh the harms but that those traveling for health care deserve protection. II. Patients: Are They International Patients or Tourists? When medical tourists seek hospitals and physicians in a destination country, facilitators may direct them to non-licensed practitioners and questionable facilities. These facilitators, who receive commissions, may not act in the patient’s best interest. Rather, like travel agents, they base their referrals on the referral fees that hospitals or physicians pay.[7] International patients risk getting lower-quality health care from unregulated hospitals or providers. This can interfere with informed consent and increase the risk of infections. There may be an absence of medical malpractice coverage from physicians. Unregulated or unlicensed medical care may even lead to patient fatalities. Therefore, it is crucial for international patients to carefully evaluate the risks associated with “booking” their healthcare options. To mitigate these risks, it is important for international patients to thoroughly assess the accreditation status of the hospital or clinic they plan to visit. The Joint Commission International (JCI) accreditation can provide patients with an external quality assessment and assist them in making an informed decision.[8] International patients should proactively seek out certified and reputable healthcare providers and institutions to ensure both their safety and a high quality of care. Colombia has five hospitals and clinics with JCI accreditation.[9] Colombia is the third most-used destination for plastic surgery in the world; the first is Brazil, and the second is Turkey. In Colombia, one out of every three plastic surgery patients is an international patient.[10] The Colombian Association for Plastic Surgery advises all patients to check the hospital's accreditation. Patients should check the website of the local Secretary of Health in each city and see if the physician conducting the plastic surgery is listed.[11] Institutions and doctors must fully comply with requirements, including describing the procedure and obtaining informed consent from patients. It is very common to read in the media plastic surgeries conducted in what is known in Latin America as “clinicas de garage” (garage clinics) with negative results and deaths.[12] Official data covers plastic surgeries conducted at accredited institutions with registered doctors. There is a lack of data on garage clinics. There are a few things the government can do to make medical tourism safer. First, the Ministry of Health’s website should maintain a list of healthcare providers with JCI accreditation. In each city, the local Secretary of Health is responsible for providing patients with information about the quality of care of the hospitals in its region. Second, the government should take responsibility for providing accurate and comprehensive information to international patients, enabling them to make fully informed decisions regarding their medical procedures. In the context of informed consent, patients may have trouble understanding due to language barriers, terminology, and the complexity of the risks involved in medical procedures. Lastly, Congress should enact a legal framework that determines the responsibility of all parties involved in medical tourism.[13] In the unfortunate event that a medical tourist requires intensive care, it becomes imperative to determine who will bear the responsibility for their well-being and any potential financial implications. Medical tourists are not protected from errors and failures of medical procedures because the Colombia Constitution specifies that the healthcare system exclusively caters to its citizens, while coverage for foreigners is limited to emergencies only. The US State Department recommends that those traveling to Colombia have international health insurance.[14] International patients can sue doctors in Colombia for medical malpractice, referred to as medical liability.[15] The government should take responsibility for certifying medical institutions and issuing medical visas with specific requirements and regulations specific to medical tourism.[16] A new medical visa system is in place. Changing the terminology may help the government see those traveling for care as medical patients rather than medical tourists. That may lead to a different mindset and spur the government to protect them and ensure high-quality care. It may also help those traveling avoid tourism industry facilitators and find reputable surgeons and hospitals. III. Are Colombian Patients and the Local Healthcare System Benefiting from Medical Tourism? The main reason for the growth of medical tourism from developed countries to developing countries like Colombia is the excessive cost of treatment in wealthier nations.[17] Other reasons include the long queues for certain types of medical services in the home country, the availability of better technologies abroad, inadequate (or absence of) health insurance, and the unavailability[18] (or prohibition) of certain medical services in the home country.[19] The Colombian Constitution recognizes health as a fundamental right for all citizens.[20] Pursuant to the Constitution’s health mandate, Colombia designed a mandatory universal social health insurance system in 1993. It aims to achieve a fair distribution of resources, opportunities, and services while holding the government accountable.[21] Before 1993, less than 25 percent of the population had coverage; now, between 94 and 99 percent have it, regardless of income level or employment.[22] However, universal care does not entitle Colombian citizens to many of the modern surgical centers, technology, and doctors that tourists access. Local wealthy Colombian citizens tend to purchase private insurance that allows them many more healthcare options.[23] The OECD reports that only 41 percent of Colombian citizens were satisfied with the availability of the quality of care, while the OECD average is 67 percent. According to the OECD, the out-of-pocket health expenditure in Colombia is 14 percent, which is lower than the OECD average of 18 percent. Despite its recognized right to health care, the current system is not providing the quality of care that the people would prefer. Those traveling to Colombia for care are not covered by universal social health insurance and must pay for their health care[24] out of pocket or through their private insurers using international coverage.[25] Like local supplemental private insurance, medical tourists and their insurance plans tend to pay more for their care than the rate that the universal system would pay the providers for care provided to the general Colombian population. This situation often leads to higher revenue from medical tourists than local patients unless the local patients have supplemental private insurance. The mismatched payment schemes leave the local population with unequal access to healthcare resources[26] since healthcare providers prefer to cater to patients paying more than the government-subsidized insurance pays. Medical tourism “threatens to result in a dual market structure”[27] characterized by a higher-quality, expensive segment that serves wealthy nationals and foreigners alongside a lower-quality segment that caters to the poor, most of whom are covered by universal healthcare coverage.[28] Medical tourists should pay taxes or a special premium to improve the local healthcare system. While the medical tourism industry arguably generates tax revenue,[29] some additional money should flow from the medical tourists to the healthcare outlets that the local people use. Then, the country can benefit even more from promoting medical tourism while ensuring that the government and the healthcare system follow the principles of justice, beneficence, and public welfare.[30] In Colombia, Fundación Cardioinfantil, a private non-profit hospital known as “La Cardio,” is a good example of a regional leader committed to providing clinical excellence to both national and international patients.[31] About 20 years ago, La Cardio, well known for its cardiovascular health care, aimed to become the top hospital in the region (Latin America and the Caribbean) to obtain financial resources for improving its facilities. It became the first hospital in Colombia to achieve the JCI accreditation, attracting patients from countries with inadequate cardiovascular healthcare systems.[32] Foreign governments covered their citizens’ medical expenses, allowing La Cardio to fund system improvement. Currently ranked as the fifth-best clinic in Latin America and having won the Gold Award for Corporate Social Responsibility, La Cardio has received recognition for its dedication to serving economically disadvantaged Colombian patients.[33] This example demonstrates how introducing a high-paying market has not led to neglecting local patients, as resources from medical tourists are used to enhance the healthcare system for the local population. CONCLUSION The Colombian government needs to recognize that international patients are seeking medical services, not tourism or vacation experiences. Therefore, a new policy should categorize international patients separately from the tourism sector and treat them purely as patients. The introduction of medical visas may help this. Once establishing international patients are patients and not tourists, the Colombian government could impose taxes on them and allocate the funds generated to reinvest in the healthcare needs of its citizens, ensuring justice and promoting awareness of the ethical rights of international patients. At the same time, home country governments directing patients to a destination country should conduct thorough due diligence of the ethical principles applied to international patients as well as the accreditation of the destination country’s hospitals. Colombia may be aware of the implications of the difference in terms but unwilling to modify the language due to the associated costs, liabilities, and risks involved. - [1] Gaines, J., Lee, C. V. (2019). Medical tourism. Travel Medicine, 371–375. https://doi.org/10.1016/b978-0-323-54696-6.00039-2 https://www.sciencedirect.com/science/article/pii/B9780323546966000392 [2] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). https://www.reportlinker.com/p06473784/Medical-Tourism-Market-Size-Share-Trends-and-Analysis-by-Region-Service-Provider-and-Segment-Forecast.html [3] Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December). [4] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020). Characterization of the healthcare tourism in the city of Bogotá and the District of Cartagena. Clío América, 14 (28), 486-492. https://doi.org/10.21676/23897848.3941 [5] Arias-Aragonés, et al. (2020). [6] Arias- Aragones, et al. (2020). https://www.colombiaproductiva.com/ptp-sectores/historico/turismo-salud (citing the Colombian Production Transformation Program (PTP)) [7] Glenn Cohen, Patients with Passports Medical Tourism, Law, and Ethics. New York Oxford University Press, 2015, p. 25 [8] Glenn, Cohen. (2015), p. 23-24. [9] A Global Leader for Health Care Quality and Patient Safety. Joint Commission International. https://www.jointcommissioninternational.org/ (The five Colombian hospitals and clinics with JCI accreditation are two hospitals in the capital city Bogota (la Cardio and Fundación Hospital Universitario Santa Fé de Bogotá), one hospital in Cali (Clinica Inbanaco), one hospital in Medellín (Hospital Pablo Tobón), and one clinic in Florida Blanca (Fundación Cardiovascular de Colombia). Nearby countries such as Venezuela and Trinidad Tobago do not have any accredited hospitals or clinics. Ecuador and Panamá have one each, Perú has eleven, and Brazil has seventy-one.) [10] International Society of Aesthetic Plastic Surgery ISAPS (2023), ISAPS International Survey on Aesthetic/Cosmetic Procedures performed in 2022, p. 52. https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2022-full-report-and-press-releases/ (most frequently cited countries of foreign patients in Colombia are the US, Spain, and Panama.) [11] Why choose a member of the SCCP. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co/porque-elegir-un-miembro-de-la-sccp/ See also: To Find a Surgeon. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co (This website is helpful for checking the list of members of the SCCP.) [12] Cosmetic Surgeries Performed in Garage Offices can Become a Public Health Problem. Concejo de Bogotá D.C. (2022). https://concejodebogota.gov.co/cirugias-esteticas-practicadas-en-consultorios-de-garaje-se-pueden/cbogota/2015-07-17/100100.php (There are many cases of deaths resulting from illegal plastic surgeries. The local government in Bogota is aware of the deaths, as reported in the Bogota Counsel (2015)). See also Travel.State.Gov, US Department of State, Bureau of Consular Affairs. (August 17, 2023). https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html (There is a warning that says: “Although Colombia has many elective/cosmetic surgery facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in Colombia, carefully research the doctor and recovery facility you plan to use. Make sure that emergency medical facilities are available, and that professionals are accredited and qualified. Share all health information (e.g., medical conditions, medications, allergies) with your doctor before surgery.") [13] Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020), p. 490. (report “the absence of regulation and a legal framework that determines the responsibilities of each link in the production chain” as a difficulty that affects competitivity to become a leader in medical tourism in the Latin American region.) See also: Trujillo, M. A. (2023, November 24). Colombia’s New Bill on Regulating Cosmetic Surgeries. BNN Breaking. https://bnn.network/breaking-news/health/colombia-to-regulate-cosmetic-surgeries-a-step-towards-patient-safety/ (On November 22, 2023, as a response to rising cases of death and injuries associated with plastic surgeries, a bill was introduced in the Colombian House of Representatives to regulate the practice of cosmetic surgeries and protect the integrity of patients) [14] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist, https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [15] U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist. See also: Medical Tourism and Elective Surgery. The Department of State informs that “U.S. citizens have suffered serious complications or died during or after having cosmetic surgery or other elective surgery“ and “the legal options in cases of malpractice are very limited in Colombia,” https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html See also: The law firm Alvarez Gonzalez Tolosa Attorneys. (August 8, 2023). Medical Malpractice in Colombia, includes medical malpractice as one of the areas of expertise of the firm. https://www.agtattorneys.com/blog/medical-malpractice-in-colombia/ [16] Colombia recently enacted a new visa regulation (Resolution 5477 from July 22, 2022, issued by the Ministry of Foreign Affairs) effective as of October 22, 2022. No data currently exists about a "medical treatment" visa because it is a new legislation. Even though the regulation refers to the visitor as a patient and includes requirements such as (1) a letter from the medical institution explaining the treatment and approximate duration, (2) a letter explaining costs and who will pay for the treatment, (3) insurance policy, and (4) the general requirements for tourists, the regulation specifically explains that this kind of visa is considered as a TOURISM visa (art 37). [17] Glenn, Cohen. 2015 [18] Frequently Asked Questions. Bioxcellerator. https://www.bioxcellerator.com/faqs (For example, Bioxellerator stem cell therapies conducted in Medellin, Colombia, are not FDA-approved.) [19] Vovk, Viktoriia, Lyudmila Beztelesna, and Olha Pliashko. (2021). "Identification of Factors for the Development of Medical Tourism in the World" International Journal of Environmental Research and Public Health 18, no. 21: 11205. https://doi.org/10.3390/ijerph182111205 [20] Colombian Constitution. (1991). art. 49 [21] Ministry of Health and Protection. Columbia Ministry of Health. (2023). https://www.minsalud.gov.co/English/Paginas/Ministry.aspx [22] “Does Colombia’s Health System Need an Overhaul?” (March 2, 2023). The Dialogue, Latin America Advisor. https://www.thedialogue.org/analysis/does-colombias-health-system-need-an-overhaul/ [23] Health at a Glance 2021 Colombia Country Note. OECD. (2023). https://search.oecd.org/colombia/health-at-a-glance-Colombia-EN.pdf [24] Travel.State.Gov, US Department of State, Bureau of Consular Affairs. https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html [25] Glenn, Cohen. (2015). p. 2-9. [26] Banco de la República. (2023). Regional Health Inequalities in Colombia. https://www.banrep.gov.co/en/regional-health-inequalities-colombia (The Central Bank of Colombia (“Banco de la República”) in reports that despite having relatively high health coverage compared with other countries, empirical results show persistent inequalities in the healthcare system. The aim is to reduce and eventually eliminate such inequalities.) [27] Glenn, Cohen (2015), p. 158-160, citing Rupa Chanda, an Indian business professor, Trade in Health Services, 80 Bull. World Health Org. 158, 160 (2002). [28] Banco de la República. (2023). Regional Health Inequalities in Columbia. https://investiga.banrep.gov.co/es/be-1233. (Under Colombian law, it is mandatory for all employees and employers to pay 4 percent and 8 percent of the applicable salary, respectively, to the universal healthcare system (EPS) to obtain coverage for the employee and family members. This is known as the contributive system, and the funding is known as parafiscal. The unemployed obtain coverage through the government-subsidized system known as SISBEN (System of Identification of Beneficiaries of Social programs), funded with taxpayers’ money, known as fiscal funding. According to the Central Bank of Colombia (Banco de la República), “in recent years, the healthcare sector has faced financial and administrative problems that have increased the need for fiscal resources for its financing and that could affect its sustainability. Regarding the composition of the outflow, it is worth noting the cost of ensuring the contributory and subsidized regime, which on average explains 80 percent of the total system expenses during the period 2011-2022.” “Additionally, pressures derived from the Covid-19 pandemic, Venezuelan migration” and expenses derived from the increase in the subsidized system due to the high rate of unemployment and informal employment are negatively impacting financing of the healthcare system in Colombia. Additional fiscal resources are needed because the health care Colombians receive costs more than what beneficiaries pay.) [29] Statista. (2023). Revenue of the medical tourism sector in Colombia from 2019 to 2024 https://www.statista.com/statistics/1156551/colombia-revenue-medical-tourism/ [30] Glenn, Cohen. (2015), p.218 (The beneficence principle is the general moral obligation to act for the benefit of others, and some of those acts are obligatory, as is the government’s obligation concerning healthcare.) [31] Hospital Cardioinfantil Bogotá, Colombia. https://cardioinfantil.org [32] Hospital Cardioinfantil https://cardioinfantil.org (Trinidad and Tobago, Aruba, Curacao, and Panamá were the first countries with international agreements with La Cardio.) [33] Hospital Cardioinfantil Bogotá, Colombia. https://www.lacardio.org/historia/

Стилі APA, Harvard, Vancouver, ISO та ін.

49

Soled, Derek. "Distributive Justice as a Means of Combating Systemic Racism in Healthcare." Voices in Bioethics 7 (June 21, 2021). http://dx.doi.org/10.52214/vib.v7i.8502.

Повний текст джерела

Анотація:

Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. [4] Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. “What is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. [5] Bedinger, M. 2020 Apr 22. “After Uproar, Mass. Revises Guidelines on Who Gets an ICU Bed or Ventilator Amid COVID-19 Surge.” Wbur. https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus; Wigglesworth, A. 2020 May 11. “Institutional Racism, Inequity Fuel High Minority Death Toll from Coronavirus, L.A. Officials Say.” Los Angeles Times. https://www.latimes.com/california/story/2020-05-11/institutional-racism-inequity-high-minority-death-toll-coronavirus. [6] Executive Office of Health and Human Services Department of Public Health. 2020 Oct 20. “Crises Standards of Care Planning and Guidance for the COVID-19 Pandemic.” Commonwealth of Massachusetts. https://www.mass.gov/doc/crisis-standards-of-care-planning-guidance-for-the-covid-19-pandemic. [7] Emanuel, E. J., G. Persad, R. Upshur, et al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 382: 2049-55. https://doi.org/10.1056/NEJMsb2005114. [8] Salway, S., G. Mir, D. Turner, G. T. Ellison, L. Carter, and K. Gerrish. 2016. “Obstacles to "Race Equality" in the English National Health Service: Insights from the Healthcare Commissioning Arena.” Social Science and Medicine 152: 102-110. https://doi.org/10.1016/j.socscimed.2016.01.031. [9] Rawls, J. A Theory of Justice (Revised Edition) (Cambridge, MA: Belknap Press of Harvard University Press, 1999). [10] Zack, N. Applicative Justice: A Pragmatic Empirical Approach to Racial Injustice (New York: The Rowman & Littlefield Publishing Group, 2016). [11] Charatz-Litt, C. 1992. “A Chronicle of Racism: The Effects of the White Medical Community on Black Health.” Journal of the National Medical Association 84 (8): 717-25. http://hdl.handle.net/10822/857182. [12] Washington, H. A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday, 2006). [13] d'Oliveira, A. F., S. G. Diniz, and L. B. Schraiber. 2002. “Violence Against Women in Health-care Institutions: An Emerging Problem.” Lancet. 359 (9318): 1681-5. https://doi.org/10.1016/S0140-6736(02)08592-6. [14] Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 9 (4): e1184. https://doi.org/10.7759/cureus.1184; Drescher, J., A. Schwartz, F. Casoy, et al. 2016. “The Growing Regulation of Conversion Therapy.” Journal of Medical Regulation 102 (2): 7-12. https://doi.org/10.30770/2572-1852-102.2.7; Stroumsa, D. 2014. “The State of Transgender Health Care: Policy, Law, and Medical Frameworks.” American Journal of Public Health. 104 (3): e31-8. https://doi.org/10.2105/AJPH.2013.301789. [15] Stepanikova, I., and G. R. Oates. 2017. “Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.” American Journal of Preventative Medicine. 52 (1s1): S86-s94. https://doi.org/10.1016/j.amepre.2016.09.024; Swartz, K. “Health Care for the Poor: For Whom, What Care, and Whose Responsibility?” In Cancian, M., and S. Danziger (Eds.). Changing Poverty, Changing Policies (New York: Russell Sage Foundation Press, 2009), 69-74. [16] Meghani, S. H., E. Byun, and R. M. Gallagher. 2012. “Time to Take Stock: A Meta-analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States.” Pain Medicine 13 (2): 150-74. https://doi.org/10.1111/j.1526-4637.2011.01310.x; Williams, D. R., and T. D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. https://scholar.harvard.edu/davidrwilliams/dwilliam/publications/understanding-and-addressing-racial-disparities-health. [17] Hoffman, K. M., S. Trawalter, J. R. Axt, and M. N. Oliver. 2016. “Racial Bias in Pain assessment and treatment recommendations, and false beliefs about biological Differences Between Blacks and Whites.” PNAS 113 (16): 4296-4301. https://doi.org/10.1073/pnas.1516047113. [18] Pacheco, C. M., S. M. Daley, T. Brown, M. Filipp, K. A. Greiner, and C. M. Daley. 2013. “Moving Forward: Breaking the Cycle of Mistrust Between American Indians and Researchers.” American Journal of Public Health. 103 (12): 2152-9. https://doi.org/10.2105/AJPH.2013.301480. [19] Velasco-Mondragon, E., A. Jimenez, A. G. Palladino-Davis, D. Davis, and J. A. Escamilla-Cejudo. 2016. “Hispanic Health in the USA: A Scoping Review of the Literature.” Public Health Reviews 37:31. https://doi.org/10.1186/s40985-016-0043-2. [20] Cameron, K. A., J. Song, L. M. Manheim, and D. D. Dunlop. 2010. “Gender Disparities in Health and Healthcare Use Among Older Adults.” Journal of Women’s Health (Larchmt) 19 (9): 1643-50. https://doi.org/10.1089/jwh.2009.1701. [21] Bierman, A. S. 2007. “Sex Matters: Gender Disparities in Quality and Outcomes of Care. Canadian Medical Association Journal 177 (12): 1520-1. https://doi.org/10.1503/cmaj.071541; Fowler, R. A., S. Sabur, P. Li, et al. 2007. “Sex-and Age-based Differences in the Delivery and Outcomes of Critical Care. Canadian Medical Association Journal 177 (12): 1513-9. https://doi.org/10.1503/cmaj.071112. [22] McLaughlin, D. K., and C. S. Stokes. 2002. “Income Inequality and Mortality in US Counties: Does Minority Racial Concentration Matter?” American Journal of Public Health 92 (1): 99-104. https://doi.org/.10.2105/ajph.92.1.99; Shea, S., J. Lima, A. Diez-Roux, N. W. Jorgensen, and R. L. McClelland. 2016. “Socioeconomic Status and Poor Health Outcome at 10 years of Follow-up in the Multi-ethnic Study of Atherosclerosis.” PLoS One 11 (11): e0165651. https://doi.org/10.1371/journal.pone.0165651. [23] Han, X., K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon. 2015. “Reports of Insurance-based Discrimination in Health care and its Association with Access to Care.” American Journal of Public Health 105 Suppl 3 (Suppl 3): S517-25. https://doi.org/10.2105/AJPH.2015.302668. [24] Aldridge, R. W., D. Menezes, D. Lewer, et al. 2019. “Causes of Death Among Homeless People: A Population-based Cross-sectional Study of Linked Hospitalization and Mortality Data in England.” Wellcome Open Research 4:49. https://doi.org/10.12688/wellcomeopenres.15151.1. [25] Richardson, E. T., M. M. Malik, W. A. Darity Jr., et al. 2021. “Reparations for Black American Descendants of Persons Enslaved in the U.S. and their Potential Impact on SARS-CoV-2 Transmission.” Social Science and Medicine 276: 113741. https://doi.org/10.1016/j.socscimed.2021.113741. [26] Wispelwey, B., and M. Morse. 2021. “An Antiracist Agenda for Medicine.” Boston Review. http://bostonreview.net/science-nature-race/bram-wispelwey-michelle-morse-antiracist-agenda-medicine. [27] Johnson, S. F., A. Ojo, and H. J. Warraich. 2021. “Academic Health Centers’ Antiracism Strategies Must Extend to their Business Practices.” Annals of Internal Medicine 174 (2): 254-5. https://doi.org/10.7326/M20-6203; Golub, M., N. Calman, C. Ruddock, et al. 2011. “A Community Mobilizes to End Medical Apartheid.” Progress in Community Health Partnerships: Research, Education, and Action 5 (3): 317-25. https://doi.org/10.1353/cpr.2011.0041. [28] New York State Bar Association. 2020. “New York State Bar Association House of Delegates: Revised COVID-19 Resolutions.” https://nysba.org/app/uploads/2020/10/Final-Health-Law-Section-COVID-19-Resolutions_10-8-20-1-1.pdf. [29] Egede, L. E. 2006. “Race, Ethnicity, Culture, and Disparities in Health Care.” Journal of General Internal Medicine 21 (6): 667-669. https://doi.org/10.1111%2Fj.1525-1497.2006.0512.x

Стилі APA, Harvard, Vancouver, ISO та ін.

50

Jamaluddin, Jazlan, Nurul Nadia Baharum, Siti Nuradliah Jamil, and Mohd Azzahi Mohamed Kamel. "Doctors Strike During COVID-19 Pandemic in Malaysia." Voices in Bioethics 7 (July 27, 2021). http://dx.doi.org/10.52214/vib.v7i.8586.

Повний текст джерела

Анотація:

Photo by Ishan @seefromthesky on Unsplash ABSTRACT A strike to highlight the plight facing contract doctors which has been proposed has received mixed reactions from those within the profession and the public. This unprecedented nationwide proposal has the potential to cause real-world effects, posing an ethical dilemma. Although strikes are common, especially in high-income countries, these industrial actions by doctors in Malaysia are almost unheard of. Reviewing available evidence from various perspectives is therefore imperative to update the profession and the complexity of invoking this important human right. INTRODUCTION Contract doctors in Malaysia held a strike on July 26, 2021. COVID-19 cases are increasing in Malaysia. In June, daily cases ranged between 4,000 to 8,000 despite various public health measures. The R naught, which indicates the infectiousness of COVID-19, remains unchanged. During the pandemic, health care workers (HCWs) have been widely celebrated, resulting in a renewed appreciation of the risks that they face.[1] The pandemic has exposed flawed governance in the public healthcare system, particularly surrounding the employment of contract doctors. Contract doctors in Malaysia are doctors who have completed their medical training, as well as two years of internship, and have subsequently been appointed as medical officers for another two years. Contract doctors are not permanently appointed, and the system did not allow extensions after the two years nor does it offer any opportunity to specialize.[2] Last week, Parliament did decide to offer a two-year extension but that did not hold off the impending strike.[3] In 2016, the Ministry of Health introduced a contract system to place medical graduates in internship positions at government healthcare facilities across the country rather than placing them in permanent posts in the Public Service Department. Social media chronicles the issues that doctors in Malaysia faced. However, tensions culminated when and contract doctors called for a strike which ended up taking place in late July 2021. BACKGROUND Over the past decade, HCW strikes have arisen mostly over wages, work hours, and administrative and financial factors.[4] In 2012, the British Medical Association organized a single “day of action” by boycotting non-urgent care as a response to government pension reforms.[5] In Ireland, doctors went on strike for a day in 2013 to protest the austerity measures implemented by the EU in response to the global economic crisis. It involved a dispute over long working hours (100 hours per week) which violated EU employment laws and more importantly put patients’ lives at risk.[6] The strike resulted in the cancellation of 15,000 hospital appointments, but emergencies services were continued. Other major strikes have been organized in the UK to negotiate better pay for HCWs in general and junior doctors’ contracts specifically.[7] During the COVID-19 pandemic, various strikes have also been organized in Hong Kong, the US, and Bolivia due to various pitfalls in managing the pandemic.[8] A recent strike in August 2020 by South Korean junior doctors and medical students was organized to protest a proposed medical reform plan which did not address wage stagnation and unfair labor practices.[9] These demands are somewhat similar to the proposed strike by contract doctors in Malaysia. As each national health system operates within a different setting, these strikes should be examined in detail to understand the degree of self-interest involved versus concerns for patient’s welfare. l. The Malaysia Strike An anonymous group planned the current strike in Malaysia. The group used social media, garnering the attention of various key stakeholders including doctors, patients, government, and medical councils.[10] The organizers of the strike referred to their planned actions as a hartal. (Although historically a hartal involved a total shutdown of workplaces, offices, shops, and other establishments as a form of civil disobedience, the Malaysian contract doctors pledged no disturbance to healthcare working hours or services and intend a walk-out that is symbolic and reflective of a strike.)[11] The call to action mainly involved showing support for the contract doctors with pictures and placards. The doctors also planned the walk-out.[12] Despite earlier employment, contract medical doctors face many inequalities as opposed to their permanent colleagues. These include differences in basic salary, provisions of leave, and government loans despite doing the same job. The system disadvantages contract doctors offering little to no job security and limited career progression. Furthermore, reports in 2020 showed that close to 4,000 doctors’ contracts were expected to expire by May 2022, leaving their futures uncertain.[13] Some will likely be offered an additional two years as the government faces pressure from the workers. Between December 2016 and May 2021, a total of 23,077 contract doctors were reportedly appointed as medical officers, with only 789 receiving permanent positions.[14] It has been suggested that they are appointed into permanent positions based on merit but the criteria for the appointments remain unclear. Those who fail to acquire a permanent position inevitably seek employment elsewhere. During the COVID-19 pandemic, there have been numerous calls for the government to absorb contract doctors into the public service as permanent staff with normal benefits. This is important considering a Malaysian study that revealed that during the pandemic over 50 percent of medical personnel feel burned out while on duty.[15] This effort might be side-lined as the government prioritizes curbing the pandemic. As these issues remain neglected, the call for a strike should be viewed as a cry for help to reignite the discussions about these issues. ll. Right to strike The right to strike is recognized as a fundamental human right by the UN and the EU.[16] Most European countries also protect the right to strike in their national constitutions.[17] In the US, the Taft-Hartley Act in 1947 prohibited healthcare workers of non-profit hospitals to form unions and engage in collective bargaining. But this exclusion was repealed in 1947 and replaced with the requirement of a 10-day advanced written notice prior to any strike action.[18] Similarly, Malaysia also recognizes the right to dispute over labor matters, either on an individual or collective basis. The Industrial Relations Act (IRA) of 1967[19] describes a strike as: “the cessation of work by a body of workers acting in combination, or a concerted refusal or a refusal under a common understanding of a number of workers to continue to work or to accept employment, and includes any act or omission by a body of workers acting in combination or under a common understanding, which is intended to or does result in any limitation, restriction, reduction or cessation of or dilatoriness in the performance or execution of the whole or any part of the duties connected with their employment” According to the same act, only members of a registered trade union may legally participate in a strike with prior registration from the Director-General of Trade Unions.[20] Under Section 43 of the IRA, any strike by essential services (including healthcare) requires prior notice of 42 days to their employer.[21] Upon receiving the notice, the employer is responsible for reporting the particulars to the Director-General of Industrial Relations to allow a “cooling-off” period and appropriate action. Employees are also protected from termination if permitted by the Director-General and strike is legalized. The Malaysian contract healthcare workers’ strike was announced and transparent. Unfortunately, even after legalization, there is fear that the government may charge those participating in the legalized strike.[22] The police have announced they will pursue participants in the strike.[23] Even the Ministry of Health has issued a warning stating that those participating in the strike may face disciplinary actions from the ministry. However, applying these laws while ignoring the underlying issues may not bode well for the COVID-19 healthcare crisis. lll. Effects of a Strike on Health Care There is often an assumption that doctors’ strikes would unavoidably cause significant harm to patients. However, a systematic review examining several strikes involving physicians reported that patient mortality remained the same or fell during the industrial action.[24] A study after the 2012 British Medical Association strike has even shown that there were fewer in-hospital deaths on the day, both among elective and emergency populations, although neither difference was significant.[25] Similarly, a recent study in Kenya showed declines in facility-based mortality during strike months.[26] Other studies have shown no obvious changes in overall mortality during strikes by HCWs.[27] There is only one report of increased mortality associated with a strike in South Africa[28] in which all the doctors in the Limpopo province stopped providing any treatment to their patients for 20 consecutive days. During this time, only one hospital continued providing services to a population of 5.5 million people. Even though their data is incomplete, authors from this study found that the number of emergency room visits decreased during the strike, but the risks of mortality in the hospital for these patients increased by 67 percent.[29] However, the study compared the strike period to a randomly selected 20-day period in May rather than comparing an average of data taken from similar dates over previous years. This could greatly influence variations between expected annual hospital mortality possibly due to extremes in weather that may exacerbate pre-existing conditions such as heart failure during warmer months or selecting months with a higher incidence of viral illness such as influenza. Importantly, all strikes ensured that emergency services were continued, at least to the degree that is generally offered on weekends. Furthermore, many doctors still provide usual services to patients despite a proclaimed strike. For example, during the 2012 BMA strike, less than one-tenth of doctors were estimated to be participating in the strike.[30] Emergency care may even improve during strikes, especially those involving junior doctors who are replaced by more senior doctors.[31] The cancellation of elective surgeries may also increase the number of doctors available to treat emergency patients. Furthermore, the cancellation of elective surgery is likely to be responsible for transient decreases in mortality. Doctors also may get more rest during strike periods. Although doctor strikes do not seem to increase patient mortality, they can disrupt delivery of healthcare.[32] Disruptions in delivery of service from prolonged strikes can result in decline of in-patient admissions and outpatient service utilization, as suggested during strikes in the UK in 2016.[33] When emergency services were affected during the last strike in April, regular service was also significantly affected. Additionally, people might need to seek alternative sources of care from the private sector and face increased costs of care. HCWs themselves may feel guilty and demotivated because of the strikes. The public health system may also lose trust as a result of service disruption caused by high recurrence of strikes. During the COVID-19 pandemic, as the healthcare system remains stretched, the potential adverse effects resulting from doctor strikes remain uncertain and potentially disruptive. In the UK, it is an offence to “willfully and maliciously…endanger human life or cause serious bodily injury.”[34] Likewise, the General Medical Council (GMC) also requires doctors to ensure that patients are not harmed or put at risk by industrial action. In the US, the American Medical Association code of ethics prohibits strikes by physicians as a bargaining tactic, while allowing some other forms of collective bargaining.[35] However, the American College of Physicians prohibits all forms of work stoppages, even when undertaken for necessary changes to the healthcare system. Similarly, the Delhi Medical Council in India issued a statement that “under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy.”[36] On the other hand, the positions taken by the Malaysian Medical Council (MMC) and Malaysian Medical Association (MMA) on doctors’ strikes are less clear when compared to their Western counterparts. The MMC, in their recently updated Code of Professional Conduct 2019, states that “the public reputation of the medical profession requires that every member should observe proper standards of personal behavior, not only in his professional activities but at all times.” Strikes may lead to imprisonment and disciplinary actions by MMC for those involved. Similarly, the MMA Code of Medical Ethics published in 2002 states that doctors must “make sure that your personal beliefs do not prejudice your patients' care.”[37] The MMA which is traditionally meant to represent the voices of doctors in Malaysia, may hold a more moderate position on strikes. Although HCW strikes are not explicitly mentioned in either professional body’s code of conduct and ethics, the consensus is that doctors should not do anything that will harm patients and they must maintain the proper standard of behaviors. These statements seem too general and do not represent the complexity of why and how a strike could take place. Therefore, it has been suggested that doctors and medical organizations should develop a new consensus on issues pertaining to medical professional’s social contract with society while considering the need to uphold the integrity of the profession. Experts in law, ethics, and medicine have long debated whether and when HCW strikes can be justified. If a strike is not expected to result in patient harm it is perhaps acceptable.[38] Although these debates have centered on the potential risks that strikes carry for patients, these actions also pose risks for HCWs as they may damage morale and reputation.[39] Most fundamentally, strikes raise questions about what healthcare workers owe society and what society owes them. For strikes to be morally permissible and ethical, it is suggested that they must fulfil these three criteria:[40] a. Strikes should be proportionate, e., they ‘should not inflict disproportionate harm on patients’, and hospitals should as a minimum ‘continue to provide at least such critical services as emergency care.’ b. Strikes should have a reasonable hope of success, at least not totally futile however tough the political rhetoric is. c. Strikes should be treated as a last resort: ‘all less disruptive alternatives to a strike action must have been tried and failed’, including where appropriate ‘advocacy, dissent and even disobedience’. The current strike does not fulfil the criteria mentioned. As Malaysia is still burdened with a high number of COVID-19 cases, a considerable absence of doctors from work will disrupt health services across the country. Second, since the strike organizer is not unionized, it would be difficult to negotiate better terms of contract and career paths. Third, there are ongoing talks with MMA representing the fraternity and the current government, but the time is running out for the government to establish a proper long-term solution for these contract doctors. One may argue that since the doctors’ contracts will end in a few months with no proper pathways for specialization, now is the time to strike. However, the HCW right to strike should be invoked only legally and appropriately after all other options have failed. CONCLUSION The strike in Malaysia has begun since the drafting of this paper. Doctors involved assure that there will not be any risk to patients, arguing that the strike is “symbolic”.[41] Although an organized strike remains a legal form of industrial action, a strike by HCWs in Malaysia poses various unprecedented challenges and ethical dilemmas, especially during the pandemic. The anonymous and uncoordinated strike without support from the appropriate labor unions may only spark futile discussions without affirmative actions. It should not have taken a pandemic or a strike to force the government to confront the issues at hand. It is imperative that active measures be taken to urgently address the underlying issues relating to contract physicians. As COVID-19 continues to affect thousands of people, a prompt reassessment is warranted regarding the treatment of HCWs, and the value placed on health care. [1] Ministry of Health (MOH) Malaysia, “Current situation of COVID-19 in Malaysia.” http://covid-19.moh.gov.my/terkini (accessed Jul. 01, 2021). [2] “Future of 4,000 young doctors who are contract medical officers uncertain,” New Straits Times - November 26, 2020. https://www.nst.com.my/news/nation/2020/11/644563/future-4000-young-doctors-who-are-contract-medical-officers-uncertain [3] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [4] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327; G. Russo et al., “Health workers’ strikes in low-income countries: the available evidence,” Bull. World Health Organ., vol. 97, no. 7, pp. 460-467H, Jul. 2019, doi: 10.2471/BLT.18.225755. [5] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [6] E. Quinn, “Irish Doctors Strike to Protest Work Hours Amid Austerity,” The Wall Street Journal, 2013. https://www.wsj.com/articles/no-headline-available-1381217911?tesla=y (accessed Jun. 29, 2021). [7] “NHS workers back strike action in pay row by 2-to-1 margin,” The Guardian, 2014. https://www.theguardian.com/society/2014/sep/18/nhs-workers-strike-pay-unison-england (accessed Jun. 29, 2021); M. Limb, “Thousands of junior doctors march against new contract,” BMJ, p. h5572, Oct. 2015, doi: 10.1136/bmj.h5572. [8] J. Parry, “China coronavirus: Hong Kong health staff strike to demand border closure as city records first death,” BMJ, vol. 368, no. February, p. m454, Feb. 2020, doi: 10.1136/bmj.m454; “MultiCare healthcare workers strike, urging need for more PPEs, staff support,” Q13 FOX, 2020. https://www.q13fox.com/news/health-care-workers-strike-urging-need-for-ppes-risks-on-patient-safety (accessed Jun. 29, 2021); “Bolivia healthcare workers launch strike in COVID-hit region,” Al Jazeera, 2021. https://www.aljazeera.com/news/2021/2/9/bolivia-healthcare-workers-strike-covid-hit-region (accessed Jun. 29, 2021). [9] K. Arin, “Why are Korean doctors striking?” The Korea Herald, 2020. http://www.koreaherald.com/view.php?ud=20200811000941 (accessed Jun. 29, 2021). [10] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [11] “Hartal,” Oxford Advanced Learner’s Dictionary. https://www.oxfordlearnersdictionaries.com/definition/english/hartal (accessed Jun. 29, 2021). [12] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [13] R. Anand, “Underpaid and overworked, Malaysia’s contract doctors’ revolt amid Covid-19 surge,” The Straits Times, 2021. [14] Anand. [15] N. S. Roslan, M. S. B. Yusoff, A. R. Asrenee, and K. Morgan, “Burnout prevalence and its associated factors among Malaysian healthcare workers during covid-19 pandemic: An embedded mixed-method study,” Healthc., vol. 9, no. 1, 2021, doi: 10.3390/healthcare9010090. [16] Maina Kiai, “Report by the Special Rapporteur on the Right to Freedom of Peaceful Assembly and Association,” 2016. [Online]. Available: http://freeassembly.net/wp-content/uploads/2016/10/A.71.385_E.pdf. [17] ETUI contributors, Strike rules in the EU27 and beyond. The European Trade Union Institute. ETUI, 2007. [18] National Labor Relations Board, National Labor Relations Act. 1935, pp. 151–169. [19] Ministry of Human Resources, Industrial Relations Act 1967 (Act 177), no. October. 2015, pp. 1–76. [20] Article 10 of the Federal Constitution states that all citizens have the right to form associations including registered trade or labor unions. A secret ballot with two-third majority will suffice to call for a strike required for submission to the DGTU within 7 days as stated in Section 25(A) of the Trade Union Act 1959. [21] Ministry of Human Resources Malaysia, Guidelines on Strikes, Pickets and Lockouts in Malaysia. Putrajaya, 2011. [22] Ordinance Emergency which was declared in Malaysia since 12 January 2021. Under the Ordinance Emergency, the king or authorized personnel may, as deemed necessary, demand any resources. [23] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [24] S. A. Cunningham, K. Mitchell, K. M. Venkat Narayan, and S. Yusuf, “Doctors’ strikes and mortality: A review,” Soc. Sci. Med., vol. 67, no. 11, pp. 1784–1788, Dec. 2008, doi: 10.1016/j.socscimed.2008.09.044. [25] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [26] G. K. Kaguthi, V. Nduba, and M. B. Adam, “The impact of the nurses’, doctors’ and clinical officer strikes on mortality in four health facilities in Kenya,” BMC Health Serv. Res., vol. 20, no. 1, p. 469, Dec. 2020, doi: 10.1186/s12913-020-05337-9. [27] G. Ong’ayo et al., “Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis,” Lancet Glob. Heal., vol. 7, no. 7, pp. e961–e967, Jul. 2019, doi: 10.1016/S2214-109X (19)30188-3. [28] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [29] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [30] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [31] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [32] D. Waithaka et al., “Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County,” Int. J. Equity Health, vol. 19, no. 1, pp. 1–15, 2020, doi: 10.1186/s12939-020-1131-y. [33] The study has shown that there were 9.1% reduction in admissions and around 6% fewer emergency cases and outpatient appointments than expected. An additional 52% increase in expected outpatient appointments cancelations were made by hospitals during that period. D. Furnivall, A. Bottle, and P. Aylin, “Retrospective analysis of the national impact of industrial action by English junior doctors in 2016,” BMJ Open, vol. 8, no. 1, p. e019319, Jan. 2018, doi: 10.1136/bmjopen-2017-019319. [34] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [35] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [36] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010. [37] Malaysian Medical Association, “Malaysian Medical Association Official Website.” https://mma.org.my (accessed Jun. 29, 2021). [38] M. Toynbee, A. A. J. Al-Diwani, J. Clacey, and M. R. Broome, “Should junior doctors strike?” J. Med. Ethics, vol. 42, no. 3, pp. 167–170, Mar. 2016, doi: 10.1136/medethics-2015-103310. [39] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [40] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010; A. J. Roberts, “A framework for assessing the ethics of doctors’ strikes,” J. Med. Ethics, vol. 42, no. 11, pp. 698–700, Nov. 2016, doi: 10.1136/medethics-2016-103395. [41] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow

Стилі APA, Harvard, Vancouver, ISO та ін.

Статті в журналах з теми "American Medical Association. Physicians' Placement Service"

Оформте джерело за APA, MLA, Chicago, Harvard та іншими стилями