Accounting for Needs in Geographical Health Care Resource Allocation.

Health on the agenda in Scottish independence referendum

50 years of the inverse care law

Increasing the GP workforce will not necessarily level up healthcare provision: instead increasing GP training numbers could worsen health inequity and inequalities. This is especially true if there are fewer opportunities to learn, train and build confidence in under-served, socioeconomically deprived areas. To investigate the representation of socioeconomic deprivation in postgraduate GP training practices in Northern Ireland (NI). Socioeconomic deprivation indices and scores of GP practices in Northern Ireland were calculated. We compared the socioeconomic deprivation indices and scores of GP postgraduate training practices against general practice in NI by examining the representation of practices whose patients live in areas of blanket deprivation, higher deprivation and higher affluence. Of 319 practices in NI, 171 (54%) were registered as postgraduate training practices with a mean deprivation score of 3.02 (95% CI 2.91-3.12) compared with non-training practices' higher mean deprivation score of 3.2 (95% CI 3.01-3.33), P-value <0.05. The proportion of training practices with blanket deprivation and higher levels of deprivation was underrepresented, with the current postgraduate GP training practices having more affluent populations. Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than in other areas of the UK and better than undergraduate teaching opportunities in general practice. Health inequalities will worsen if the representation of general practice training in areas of greater social economic deprivation is not increased.

Health Disparities in Pulmonary Arterial Hypertension and the Impact of the COVID-19 Pandemic

Disparities in Vision Health and Eye Care: Where Do We Go from Here?

Photo by Sharon McCutcheon on Unsplash&#x0D; ABSTRACT&#x0D; 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.&#x0D; INTRODUCTION&#x0D; 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.&#x0D; BACKGROUND&#x0D; 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]&#x0D; ANALYSIS&#x0D; 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.&#x0D; l. Primary Theories of Justice&#x0D; 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.&#x0D; 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]&#x0D; 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.&#x0D; 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]&#x0D; 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.&#x0D; 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]&#x0D; ll. Historical and Ongoing Disparities&#x0D; 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.&#x0D; 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] &#x0D; 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]&#x0D; 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]&#x0D; lll. Action Needed: Policy Reform&#x0D; 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.&#x0D; Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-

Dear Sir, We read with interest the position statement of the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) on the use of biosimilar granulocyte colony stimulating factors (G-CSF, filgrastim) for the mobilisation of stem cells in normal haematopoietic stem cell donors which was recently published on the SIMTI website1. SIMTI and the Italian Bone Marrow Donor Registry (IBMDR) share the concern of the World Marrow Donor Association (WMDA) about the use of biosimilar G-CSF in donors of haematopoietic stem cell for allogeneic transplantation2. Recently, several similar biotherapeutic filgrastim products have become available on the market at lower cost than their reference therapeutic products, whose patents have expired. These products are manufactured using separately developed and similarly proprietary processes. Although a similar efficacy for primary licensing indications was demonstrated, “differences in their ultimate clinical efficacy, adverse event profile and immunogenicity” cannot be excluded and, “because of these possible differences, late-effects may also vary”2. “As the efficacy for mobilization is extrapolated, with little safety analysis and no long-term follow up, the WMDA recommends that biosimilars not be used for mobilization in normal donors unless the donor is followed on a study (…). Only when comprehensive data to confirm long-term safety and efficacy is available should use of G-CSF biosimilars be considered routine2”. The therapeutic equivalence of G-CSF biosimilars has been extrapolated to all the indications of filgrastim, including peripheral blood stem cell mobilisation and transplantation, even though they have been granted marketing authorisation on the basis of results of studies in cancer neutropenia3. Key concepts and critical issues on biosimilars have also been conveyed in a position paper by the Italian Society of Hematology (SIE), the Italian Society of Experimental Hematology (SIES), and the Italian Group for Bone Marrow Transplantation (GITMO)3. SIE, SIES and GITMO state that the “evaluation of the appropriate use of a biosimilar in clinical practice, as for any new drug, should be based on a critical appraisal of the benefit/cost ratio, grounded on the evidence of efficacy and tolerability, in particular on the documented equivalence between the biosimilar and the reference product3”. They also state that a patient who is well treated with a particular filgrastim (independently of cost and whether it is an originator or a biosimilar) should not undergo a change in treatment for purely economic reasons. In addition to the importance of the full awareness of all the decision elements by the professionals who use biosimilars, the above scientific societies stress the role of the traceability of the prescriptions of these drugs for an effective pharmacovigilance. For this reason the current International Non-proprietary Name system (which gives the same name to drugs with the same active ingredient, irrespective of their productive process) should not be used in order to ensure that adverse events are assigned to the correct product. Over the past decade, a major shift has occurred from bone marrow to cytokine-mobilised peripheral blood stem cells as the prevailing source of allogeneic haematopoietic cell grafts. Although haematopoietic stem cell donors generally recognise that the donation of peripheral blood stem cells is not risk-free, it is the responsibility of the transplant community to understand these risks, to minimise them and to provide donors with exhaustive information, keeping in mind that the health and well-being of the donor must be a priority. There is a large amount of literature on the ethical value of the donation of blood. The provocative book “The gift relationship: from human blood to social policy” published in 1970 by British social scientist Richard M. Titmuss is a well-known source for this topic. Blood and haematopoietic stem cell donation are strong forms of solidarity. Solidarity, considered as a perception of mutual obligations between the members of a community, is deeply rooted in human experience and thinking. Solidarity is also a core value of many National Health Services. The literature distinguishes between “benevolent solidarity”, in which the donor can also be one of the beneficiaries, and “altruistic solidarity”, in which only other people benefit from the donation: blood and haematopoietic stem cell donors make a humanitarian gesture rewarded solely by feelings of altruism. According to “The short Routledge encyclopedia of philosophy”, “solidarity exits among a group of people when they are committed to abiding by the outcome of some process of collective decision-making, or to promoting the well-being of other members of the group, perhaps at significant costs to themselves”. Nevertheless, the prospect of asking healthy donors to assume potential and unassessed additional “costs” (in this case: physical risks) as part of their donation raises important ethical issues that we would like to address. At present, it is unknown whether the safety profile of reference biotherapeutic products for the mobilisation of peripheral blood stem cells in normal haematopoietic stem cell donors can be extended to biosimilars. From an ethical perspective, two main elements should be considered under these circumstances: (i) risk management; (ii) decisions regarding allocation of resources. The donation of any type of blood or cells must never jeopardise a donor’s health beyond standard risks for the blood and cell collection. As insufficient evidence from safety analysis and long-term follow up is available, donors treated with G-CSF should be considered human research subjects without the prospect of clinical benefit and with the potential to improve health and well-being for others. Translated from the World Medical Association’s Declaration of Helsinki, the priority principle applies to the health and well-being of the donor (article 6). This principle takes precedence over the interests of science and society. All major ethical codes and documents are unequivocal on this point. Moreover, potential risks due to biosimilar G-CSF (for which available scientific data are insufficient and uncertain) would require a cautionary approach. In bioethics, the precautionary principle is an action principle applied to deal with potential risks for which available scientific data are insufficient, uncertain or contradictory. Precaution has become crucial in medical ethics. Indeed, some authors have juxtaposed the so-called “principles of bioethics” (autonomy, beneficence/non-maleficence, justice) to three other principles: dignity, precaution, solidarity. In this perspective, we should take the centrality of the precautionary principle as a starting point for medical ethics. As the UNESCO Universal Declaration on Bioethics and Human Rights states: “In applying and advancing scientific knowledge, medical practice and associated technologies, direct and indirect benefits to patients, research participants and other affected individuals should be maximized and any possible harm to such individuals should be minimized”. Nevertheless, the situation of volunteer donors is different from that of most other research subjects because donors are asked to donate haematopoietic stem cells for patients who are known to have life-threatening disease. The donor’s “benefit” is altruism: donation of blood and cells can only be justified as a free and disinterested expression of solidarity. Solidarity is perceived as a caring and generous attitude towards other people, as putting others’ best interests before one’s own, with no expectation of reward. Non-market values, such as altruism and solidarity, need a suitable environment. Procedures should be established to ensure both timely donation of high-quality haematopoietic stem cells and adequate safeguards for donors. Concern over the optimal allocation of health care resources has become increasingly acute in an era of rising medical costs and cost-containment. Control of pharmaceutical spending has been one of the important cost-containment measures introduced by recent Italian health care policy. Curtailment of public expenditure should not threaten the safety of the patient (and donor), which is “central to the clinical governance framework”: “The allocation of healthcare resources should aim at and be justified by the improvement in people’s health (…). Improving health should be the primary goal”. As the World Medical Association Declaration on the Rights of the Patients states: “choice must be based on medical criteria”5. In conclusion, we thoroughly agree with SIMTI, SIE, SIES, GITMO and WMDA position statements, believing that the choice of using biosimilar G-CSF is not justifiable by a cost-containment policy and is in contrast with the priority principle of protecting those allogeneic haematopoietic stem cell donors who, with their donation, contribute greatly to providing transplant recipients with the essential levels of health care that the National Health Service must deliver them.

Medical ethics and medical education.

National Health Service: not for sale

Can competition enhance efficiency in health care? Lessons from the reform of the U.K. national health service.

The increase in the prevalence of autism spectrum disorder has placed greater demands on the health care system. Children and adolescents with autism spectrum disorder often experience challenges accessing high-quality physical and mental health care due to characteristic social-communication deficits and behavioral difficulties, as well as high rates of complex medical and psychiatric comorbidities. Intellectual disability commonly co-occurs with autism spectrum disorder and individuals affected by this co-occurrence may have additional impairments that compound challenges accessing health care. This study investigated the relations among co-occurring intellectual disability, unmet physical and mental health care needs, and health care quality in a large, nationally distributed sample of youth with autism spectrum disorder using structural equation modeling techniques. Co-occurring intellectual disability was significantly associated with unmet mental health care needs in children with autism. In addition, unmet mental health care needs mediated the relationship between co-occurring intellectual disability and health care quality; youth with autism spectrum disorder and co-occurring intellectual disability who had a past-year unmet mental health need had significantly poorer caregiver-reported health care quality. These findings suggest that youth with autism spectrum disorder and co-occurring intellectual disability may be more likely to experience unmet mental health care needs and receive poorer quality of care than the broader autism spectrum disorder population.

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community in terms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services.

There is growing interest in the use of “distributionally-sensitive” forms of economic evaluation that capture both the impact of an intervention upon average population health and the distribution of that health amongst the population. This review aims to inform the conduct of distributionally sensitive evaluations in the UK by answering three questions: (1) How averse are the UK public towards inequalities in lifetime health between socioeconomic groups? (2) Does this aversion differ depending upon the type of health under consideration? (3) Are the UK public as averse to inequalities in health between socioeconomic groups as they are to inequalities in health between neutrally framed groups? EMBASE, MEDLINE, EconLit, and SSCI were searched for stated preference studies relevant to these questions in October 2017. Of the 2155 potentially relevant papers identified, 15 met the predefined hierarchical eligibility criteria. Seven elicited aversion to inequalities in health between socioeconomic groups, and eight elicited aversion between neutrally labelled groups. We find general, although not universal, evidence for aversion to inequalities in lifetime health between socioeconomic groups, albeit with significant variation in the strength of that preference across studies. Second, limited evidence regarding the impact of the type of health upon aversion. Third, some evidence that the UK public are more averse to inequalities in lifetime health when those inequalities are presented in the context of socioeconomic inequality than when presented in isolation.

Has traditional medicine had its day? The need to redefine academic medicine

Objective To investigate whether the policy of increasing National Health Service funding to a greater extent in deprived areas in England compared with more affluent areas led to a reduction...