North American Health Care Systems Research Articles

Understanding patient, caregiver, and healthcare provider perspectives of the management of long-chain fatty acid oxidation disorders.

Long-chain fatty acid oxidation disorders (LC-FAODs) are a group of rare, inherited, metabolic disorders that can lead to a wide range of symptoms that predominantly affect organ systems with high energy needs, such as the heart, liver, skeletal muscle, and nervous system. Clinical management primarily consists of close attention to and monitoring of diet and activity and avoidance of prolonged fasting. In addition, patients and caregivers must be alert for signs of life-threatening metabolic decompensation. As a result, LC-FAODs can have significant and wide-ranging impacts on the lives of patients and their caregivers. This article describes the effects of LC-FAODs at different life stages and in the context of the North American healthcare system from the perspective of a group of patients, caregivers, and healthcare providers (n = 6). We explain how challenges and needs change throughout life. Following an early diagnosis, an adjustment phase occurs during which caregivers may feel overwhelmed by their new roles and deeply concerned for their children's futures. As children grow, they become more aware of the differences between themselves and their peers, and with increasing independence comes more responsibility for managing their own condition. Major life events, such as new employment and moving house, pose challenges for people of all ages. In addition, it may be difficult to find and connect with qualified and experienced healthcare providers; navigate the health insurance system; and educate and align primary, specialist, and emergency care providers. We propose several strategies to improve the care of patients with LC-FAODs, such as educating local healthcare teams, improving trust between patients/caregivers and healthcare providers, and raising awareness of the challenges faced by patients and caregivers across the different life stages.

Intraincisional Pin Placement is Safe for Robotic-Assisted Total Knee Arthroplasty

BackgroundWhile robotic-arm assisted total knee arthroplasty (RA-TKA) has seen a major increase in its utilization, it requires bone array pins to be fixed into the femur and tibia, which intrinsically carries a risk. As it is currently off-label with some robotic platforms to place pins intraincisional, we aimed to evaluate the safety of intraincisional pin placement during RA-TKAs. MethodsA prospective cohort of 2,343 patients who underwent RA-TKA at a North American Healthcare System between January 2018 and March 2022 was included. Primary outcomes included periprosthetic fracture or infection (eg, superficial or deep). Secondary outcomes included 1-year reoperation rate due to any cause. Cases were retrospectively reviewed to determine whether complications could be attributed to metaphyseal intraincisional pin placement (4.0 mm pins; two tibial and two femoral). The 90-day follow-up was 100% and the 1-year follow-up rate was 70.6% (n = 1,655). ResultsThe pin-site related periprosthetic fracture incidence at 90 days was 0.09% (2 out of 2,343). The 90-day infection incidence was 1.4% (superficial: 22; deep: 13). The 1-year reoperation rate was 1.8% (29 out of 1,655). The most common causes of reoperation at 1-year were deep infection (n = 14; 0.83%), superficial infection (n = 3; 0.18%), periprosthetic fracture, mechanical symptoms, instability, and hematoma (n = 2; 0.12% for each). ConclusionsOne in 1,172 patients may experience a pin-related periprosthetic fracture after RA-TKA with intraincisional bone array pin placement. There was a low 90-day infection incidence and reoperations within 1-year after RA-TKA were rare.

Uprooting Medical Violence: Excavating the Roots of Settler Colonialism and Systemic Anti-Black Racism within Healthcare.

In this issue, Dryden (2023) disrupts the myth of neutrality in healthcare and outlines the importance of naming anti-Black racism in order to dismantle it. In this commentary, I take up Dryden's (2023) call to study the relationship between colonialism, anti-Blackness and healthcare. I utilize historical and present-day examples that uncover the roots of settler colonialism and slavery within North American healthcare systems. Finally, I explore how dispossessed communities have resisted medical violence. I call on healthcare workers to fight for non-reformist reforms, uplift self-determining care and engage in resistance toward liberatory futures.

The Fentanyl System Shock - Are There Lessons to Learn From the COVID-19 System Shock Framework? Comment on "The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic".

The Sydney Children's Hospitals Network (SCHN) addressed the challenges of the COVID-19 pandemic by implementing innovative changes which made their health system resilient and responsive. For other healthcare systems, there are important takeaways. In the United States and Canada, an urgent widespread response is needed to address the overdose crisis, driven by potent synthetic opioids (ie, fentanyl and its derivates). We project the COVID-19 System Shock Framework (CSSF) on to the North American healthcare systems and suggest a Fentanyl System Shock Framework, which provides a framework for necessary changes and innovations to address the overdose crisis. To become resilient to the fentanyl system shock, core components as well as overarching values, health policy, and online technologies need to be adapted to reduce the death count and meet the evolving needs of marginalised individuals who use opioid. Future research should focus on scientifically assessing such implementations to guide evidence-based decision making.

Validation of a Novel Smartphone-Based Electronic Data Capture System Following Surgical Fixation of Distal Radial Fractures.

Large prospective institutional data provide the opportunity to conduct level II and III studies using robust methodologies and adequately powered sample-sizes, while circumventing limitations of retrospective databases. We aimed to validate a prospective data collection tool, the Orthopaedic Minimal Data Set Episode of Care (OME), implemented at a tertiary North American health care system for distal radial fracture (DRF) open reduction and internal fixation (ORIF). The first 100 DRF ORIFs performed after OME inception (February 2015) were selected for this validation study. A blinded review of the operative notes and charts was performed, and extracted data of 75 perioperative DRF ORIF procedure variables were compared with OME collected data for agreement. Outcomes included completion rates and agreement measures in OME versus electronic medical record (EMR)-based control datasets. Data counts were evaluated using raw percentages and McNemar tests. Cohen (κ) and concordance correlation coefficient analyzed categorical and numerical variable agreement, respectively. Overall, OME demonstrated superior completion and agreement parameters versus EMR-based retrospective review. Nine data points (12.0%) demonstrated significantly higher completion rates within the OME dataset (P < .05, each), and 88% (66/75) of captured variables demonstrated similar completion rates. Up to 80.0% (60/75) of variables either demonstrated an agreement proportion of ≥0.90 or were solely reported in the OME. Of 33 variables eligible for agreement analyses, 36.4% (12/33) demonstrated almost perfect agreement (κ > 0.80), and 63.6% (21/33) exhibited almost perfect or substantial agreement (κ > 0.60). The OME is a valid and accurate prospective data collection tool for DRF ORIF that is reliably able to match or supersede traditional retrospective chart review. Future investigations could use this tool for large-scale analyses investigating peri/intraoperative DRF ORIF variables.

Clinical Outcomes of Conical Hip Prosthesis Used In Primary Total Hip Arthroplasty

Introduction: Congenital dysplasia of the hip, presence of intramedullary bony pedestals, and related pathologies present unique challenges to the orthopaedic surgeon when considering total hip arthroplasty (THA). In these circumstances, a conical prosthesis has proven to be effective. The purpose of this study is to report the short-term radiological and clinical outcomes of the Wagner Cone Prosthesis® (Zimmer Biomet, Warsaw, Indiana) utilized for a range of etiologies at a major North American healthcare system. Materials and Methods: A retrospective study was performed at a single healthcare system between 2007 and 2018. Demographic variables, including age, sex, and laterality, as well as surgical variables, including femoral head size, neck-shaft angle, stem diameter, surgical approach, and indication for THA, were collected for each hip. Radiographs were also examined for subsidence, limb length discrepancy (LLD), and Crowe classification if the hip was dysplastic. Results: Thirty-one THAs were performed using a Wagner Cone Prosthesis®. No intraoperative or postoperative implant-related complications were reported. Fourteen hips were dysplastic, and of these, 10 were classified as Crowe I, one as Crowe II, two as Crowe III, and one as Crowe IV. No implant was observed to have subsidence greater than 1cm. The average LLD following arthroplasty was 1.38mm ± 9.4mm shorter than the contralateral side. Conclusion: The Wagner Cone Prosthesis® serves as a useful implant for THA. In our sample, it had excellent survivorship, impressive postoperative radiographic measurements obtained from most recent follow up, minimal mean subsidence, and minimal complication rates.

Profesija sestrinstva u savremenom sistemu zdravstvene zaštite i javnom zdravlju - nove uloge i izazovi

Given the general importance of caring for the health of the population, it is understood that the healthcare system is organizationally one of the most complex systems in a country, with elements that should provide physically, geographically, and economically accessible, integrated and quality healthcare. Historically, nursing as a profession has gone through several developmental stages, always trying to respond to professional challenges and follow modern trends and needs of society. By defining nursing as an integral and independent profession within the healthcare system, the modern nurse is faced with a number of professional, educational, and social challenges, especially in those countries where the nursing profession still has an inadequate social image, both in public and professional environment. The change of nurses professional role in reformed European and North American healthcare systems ̓ is particularly visible in primary health care and public health, where nurses have taken on one of the leading roles in the organization of the work process. With a unique professional focus that can be directed on the individual and family, or system and community, modern nursing as a healthcare profession is extremely well-positioned to respond to the need of modern society for the integration of health services and to make an active contribution to positive changes in the modern healthcare system, at the same time.

An Opinion 11,000KM in the Making

How is medicine practiced on the other side of the world? As medical students in Canada, we learn much about pathophysiology and the North American healthcare system. Yet important observations can be made about how other cultures deliver care that can be used to help us address shortcomings of our own. In this opinion piece, I use my experience studying cardiac surgery in Shanghai, China to explore how each country confronts a similar problem: access to care in rural medicine. Despite their differences, both China and Canada come to creative solutions, reflecting the incredible diversity of their patients.

Emotional Intelligence and Online Healthcare

As the North American healthcare system moves to online value-based care, the importance of engaging patients and families continues to intensify. However, simply engaging patients and families to improve their subjective satisfaction will not be enough for providers who want to maximize value. True optimization entails developing deep and long-term relationships with patients through understanding their needs. This article discusses the result of a research conducted in Canada. Out of 1100 questionnaires which were distributed, 850 valid returns were obtained. The collected data were analyzed using a SPSS 20.0 statistical. The findings indicate that IT healthcare is rapidly growing. However, despite a significant number of initiatives in Canada related to online health information, lack of interoperability remains one of the major challenges in implementing successful health IT systems at this time.

Current Pediatric Emergency Department Innovative Programs to Improve the Care of Psychiatric Patients.

Emergency departments (EDs) across North America have become a safety net for patients seeking mental health (MH) services. The prevalence of families seeking treatment of children in MH crisis has become a national emergency. To address MH access and improve quality and efficient management of children with MH conditions, the authors describe ED projects targeting this vulnerable population. Five North American health care systems volunteered to feature projects that seek to reduce ED visits and/or improve the care of MH patients: Allina Health, Nationwide Children's Hospital, Children's Hospital of Eastern Ontario, Connecticut Children's Medical Center, and Rhode Island Hospital.

A solução para o SUS não é um Brazilcare

O Sistema Único de Saúde brasileiro implantado não recebeu todos os investimentos necessários para alcançar a magnitude prevista desde sua concepção e estabelecida na Constituição Federal de 1988. No mesmo período, o setor privado de saúde brasileiro vem recebendo cada vez mais investimentos por meio das políticas públicas do Estado. A crise econômica e os problemas pelos quais o SUS passa nos dias atuais são usados por determinados atores para justificar uma suposta necessidade de diminuir não só a pressão por financiamento, mas também a demanda de serviços públicos, e apresentar como solução a diminuição do SUS concomitante à expansão do número de pessoas com planos privados de saúde nos moldes da reforma do sistema de saúde norte-americano conhecida como Obamacare. Este artigo apresenta a falácia desse raciocínio com evidências científicas e argumentos que mostram que um maior investimento no SUS é fundamental para o desenvolvimento econômico e social do país.

Quality of surgical care of pancreatic cancer in a single payer North American health care system

Introduction: Quality of surgical care of Canadian patients with pancreatic cancer (PC) is inadequately known. Primary aim of this study was to analyze the quality of care received by patients who underwent resections of PC in Nova Scotia over a 10-year period (2001-2011). Methods: All patients with PC (n. 1094) were identified using provincial cancer registries and only adult patients with resectable disease were included in the study (n. 109). Well established disease-specific quality indicators (QIs) were used as references. The proportion of patients who met those QIs was calculated. The average and 95 % confidence intervals of QIs were compared between patients treated in Nova Scotia and published references. Results: Surgical therapy was performed in 9.9 % of patients. Perioperative morbidity and mortality occurred in 25 % and 5 % of patients respectively. Overall survival was 57 % at 1 year, 18 % at 3 year and 9 % at 5 year. R1 resections occurred in 38 % of patients. When compared to published quality measures, patients in Nova Scotia had similar outcomes except for an inferior number of lymph nodes found in the surgical specimens (9 vs. 19; P&lt;0.05). On the other hand, a significant proportion of patients did not fully meet several QIs linked to preoperative, surgical pathology and postoperative care. Conclusions: In Nova Scotia, the proportion of patients who underwent surgery for PC was lower than expected. Although perioperative morbidity, mortality and survival rates were comparable to published references, many did not meet established standard QIs.

BINGO: targeted therapy for advanced biliary-tract cancer

Although biliary-tract cancers are infrequent in European and North American health-care systems, they pose a substantial challenge worldwide. Few patients with biliary-tract cancers (cholangiocarcinomas, gallbladder cancer, and ampullary tumours) are diagnosed at an early enough stage to be amenable to curative resection, so identification of additional therapies for many patients presenting with unresectable or metastatic disease is urgently needed.

Non‐medical use of prescription opioids and prescription opioid‐related harms: why so markedly higher in North America compared to the rest of the world?

This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions. Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated. We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America. Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.

Single-Centre, North American Experience with Compassionate Use of Deferiprone in Patients with Beta-Thalassemia Major,

Abstract 3185▪▪This icon denotes a clinically relevant abstract Introduction:Deferiprone (DFP) is a thrice daily, oral iron chelator with cardiac-specific properties. It has been demonstrated to improve LV EF% and reduce cardiac related morbidity and mortality in patients with Beta Thalassemia Major (TM). It was approved as second line therapy by European regulatory agencies in 1999, but despite being developed by a Toronto-based pharmaceutical company, has yet to be approved by Health Canada or the FDA. Since July 2004 it has been available via a compassionate use program (CUP). The Red Blood Cell Disorders Program (RBCDP, Toronto General Hospital, Canada) is Canada's largest adult Hemoglobinopathy comprehensive care centre. In mid 2009, the RBCDP took a programmatic decision to systematically enrol those patients with significant cardiac siderosis, and hence at risk of cardiac events and death, in the CUP. Patients intolerant of or having a suboptimal responsive to Deferoxamine or/and Deferasirox were also considered for DFP therapy. Here we report on a single centre experience with this oral chelator within a North American healthcare system. Methods:Approval was received from the Research Ethics Board and data was collected retrospectively from the RBCDP database, electronic patient records, and CUP monitoring records. Patients complied with weekly CBC monitoring through the use of community based laboratories with electronic transmission of results in a timely manner. All patients who were prescribed DFP for at least 12 months between January 2009 and January 2011 were included in the analysis. Efficacy data and adverse events are reported here. Results:Thirty-four patients were identified (19 females and 15 males; 29 beta-Thalassemia Major, 4 Hemoglobin E/b-Thalassemia compound heterozygote, 1 homozygous sickle cell disease) for a total of 28.72 patient-years observed. 2 patients were excluded from analysis due to incomplete data. Nineteen patients (58%) were splenectomised. Mean age at the start of DFP therapy was 31.07 years (SEM +/− 5.18 years). 16 patients received DFP in combination with another chelator. 22/34 were prescribed DFP for severe cardiac siderosis. Sixteen (48%) of the patients were prescribed at 75 mg/kg/day and 17 (52%) at 100 mg/kg/day. Mean physician-assessed adherence rate was 68% (SEM +/− 12%), with 64% of patients having >90% adherence rate. Serial T2* and ejection fraction (EF) measurements from cardiac MRI were available in 22 patients, with a mean change in T2* of +2.6 ms/year (SEM +/− 0.5 ms/year) and EF +1.5%/year (SEM +/− 0.3%/year). There was a significant change in T2* measurements after an average of 425 days (SEM +/− 91 days) of DFP therapy (P=0.0006). No significant change was observed in LIC (−2.84 mg/g dry weight; P = 0.067) or ferritin values (542.6 umol/L; P=0.327). Neutropenia (ANC < 1.5) was observed in 4 patients totalling 11 instances but no agranulocytosis was observed. Four patients had an asymptomatic transient increase in alanine transferase (> 5x upper limit of normal). Four patients had arthralgias, which resolved with dose reduction. Discussion:We believe that the RBCDP currently has the largest active population of patients receiving chelation with DFP in North America. Initial data presented here demonstrates the drug to be effective in controlling cardiac iron overload; is well tolerated; and reveals no new adverse effects. Our experience mirrors that of Thalassemia centres outside of North America over the past 10 years. Longer follow up of this cohort is ongoing. Disclosures:Off Label Use: Deferiprone is an unlicensed medication in USA and Canada, and is available through compassionate use. It is an oral iron chelator. Kuo:Novartis Canada: Research Funding.

Clinical ethics committees

<h2>Abstract</h2> The contribution describes the current status of clinical ethics committees in the UK, charting their development and showing the extent of their current distribution. The situation in the UK is compared to the status of clinical ethics in the North American health-care system. The differences between clinical ethics committees and research ethics committees are explained, with the structure and functions of clinical ethics committees described in more detail. The future of clinical ethics committees in the UK is discussed, as is the support provided by the UK Clinical Ethics Network.

Active surveillance systems for pediatric adverse drug reactions: an idea whose time has come

Background: The North American health care system has relied steadfastly on the idea of a voluntary surveillance system for adverse drug reactions (ADRs). Nevertheless, ADRs continue to be a major cause of morbidity and mortality. The economic cost of ADRs has been estimated to be between $30 billion and $130 billion annually. Modifications of existing passive surveillance systems may help to improve our understanding of ADRs but are unlikely to be sufficient to achieve meaningful practice change in the prevention of serious ADRs. Objective: Active surveillance systems are likely to help significantly in our understanding of the scope of the ADR problem. Increased reporting and more thorough data collection processes are 2 outcomes that are likely to occur if active surveillance systems are put in place. The Pediatric Adverse Drug Reaction Reporting Program (PADR) was developed to meet the need for an active surveillance system for pediatric patients. Conclusions: In the first phase of PADR, 3812 ADR records were actively collected. In the next phase, PADR will be expanded from an initial 22 sites to as many pediatric centers within the United States, Canada, and Mexico as are willing to participate. A comprehensive strategy for the collection and analysis of data and for the implementation, dissemination, and uptake of identified practice improvements has also been proposed. Significant social problems like morbidity and mortality secondary to ADRs require new approaches and renewed commitments in order to be solved.

Advanced neonatal nurse practitioners in the United Kingdom: where are they and what do they do?

The former Wessex region was the first in England to institute an advanced neonatal nurse practitioner (ANNP) course within the United Kingdom (UK), and at the time of this survey three cohorts had completed the course. The role has been developed over several years in the North American health care system, where it has been shown that ANNPs have the ability to perform as competently and efficiently as junior doctors. It is a major development both in neonatal care and nursing. Following a review of the literature on ANNPs, this paper details the distribution of ANNPs in the UK, and reports on a survey undertaken by the authors, which examined the function, clinical grading and source of funding of ANNPs, as well as examining the ANNPs' view of their role and challenges they have encountered.

Health care contracts in Britain and the United States: a case for technology transfer?

One unexpected point of convergence between the British and North American health care systems is the increased use of negotiated contracts to govern relationships between purchasers and providers. In Britain, the internal market reforms introduced a special regime of National Health Service (NHS) contracts; in the United States there has been a move from disorganization towards integration with the emergence of larger purchasing coalitions and provider organizations. While, in the past, US patients were simply billed for services or assigned claims to the provider, it is now common for payment to be made directly from purchaser to provider and for the terms of these transactions to be set out in contracts. This paper draws on the reading of contracts, interviews with contracting parties, and ongoing research on NHS contracting in Wales to compare contracting practice within the two systems. It examines how the very different environments of the public, hierarchically-regulated NHS and the private health care market of the US influence the detailed content of contract clauses. The analysis passes over similarities, different solutions to common problems, and fundamental differences of approach, before considering the possibilities for transfers of contracting 'technology'.

Narrative representations of chronic illness experience: cultural models of illness, mind, and body in stories concerning the Temporomandibular Joint (TMJ)

The narratives individuals told about their experiences with an illness they have come to understand as TMJ, a problem linked to the temporomandibular joints of the jaw, are complex. Each is embedded within a unique set of life circumstances and guided by individual schemas and explanatory models. Each recounts how persons have come to make sense of perplexing symptoms that are not easily categorized and treated within the North American health care system. Yet, in spite of their distinctiveness, the reconstructed narratives are not independent of shared cultural schemas, such as those relating to mind and body, and other shared models, such as the model for TMJ, which individuals come to adopt as a consequence of treatment and interaction with others. The consistent emergence of themes concerning the mind and body within and across narratives attest to their salience for understanding the narratives related here. While describing the effect of illness on individual lives, narratives also illuminate how shared understandings shape the interpretation and construction of individual experience.