Wednesday, April 21, 2010
We see end-of-life care as a part of good medical care, not something distinct or apart. However, we emphasize the availability of specific knowledge on end of life care through this Internet site, not because it is seperate from good medical care, but because end of life care has been neglected in the training of most health care professionals. Further, the palliative care concepts expressed in this educational material are applicable across the entire spectrum of health care, not just in end-of-life care.
We hope that you will find the site to be useful in your work with patients and families as together you face one of life's most stressful, yet meaningful, experiences. Our intent is to provide you with the tools and information that will improve your ability to provide compassionate and expert care to patients, and to care for yourself while doing so. Our ultimate goal is to improve the well being of patients at the end of their lives, and their families as they continue in their lives without their loved one.
- Provides free resources and information to help people make decisions about end-of-life care and services before a crisis.
- Brings together community, state and national partners working to improve end-of-life care through a national campaign called It's About How You LIVE.
Tuesday, April 20, 2010
William Mann of Pittsburgh earns just enough to get by. He is 46, doesn't own a car, hasn't taken a vacation in three years and hasn't had health insurance for most of his adult life.
He is just the kind of person who should benefit from the health care overhaul, and he is, in fact, eligible for heavily subsidized insurance that will cost him an estimated $1,845 a year, while the government contributes about $2,756.
But Mr. Mann says he still can't afford it. He lives too close to the edge, and won't be buying insurance, even though he will face a fine under a provision called the individual mandate, which penalizes most Americans who don't buy coverage starting in 2014. The requirement is one of the most controversial aspects of the overhaul.
"I just can't put that kind of money out for a 'maybe' — maybe I'll get sick and use it," said Mr. Mann, who makes just over $25,000 a year as an administrative assistant at a small wine distribution company. "That's a lot of money."
"The people who make all these decisions don't live like the way I do," Mr. Mann added, echoing other uninsured people in his income group. "They don't live like the rest of us."
Legal questions about the individual mandate aside, the choices made by people like Mr. Mann are crucial. One reason the individual mandate was created was to attract as many healthy people as possible to the individual market to offset the demands of the many sick people who will be buying in, and who have medical needs that drive up costs.
Yet no one really knows which way the Mr. Manns of the nation, people struggling in a tough economy, will go.
"Given the choice, a lot of people are going to purchase coverage rather than pay the penalty — they simply want the security of having health insurance," said Jennifer Tolbert, principal policy analyst at the Kaiser Commission on Medicaid and the Uninsured, an initiative of the Kaiser Family Foundation (not associated with Kaiser Permanente, the health insurance company). She said that had been the experience in Massachusetts under a similar initiative. But she added, "The key is to make coverage affordable."
According to the Congressional Budget Office, some 32 million more Americans will have insurance by 2019 under the new law, about half of whom will be buying health insurance on the individual market for the first time (the other half will be covered for the first time under Medicaid, which is being expanded to include more of the poor).
But Edmund F. Haislmaier, senior research fellow of health policy studies at the Heritage Foundation, a conservative research group, said he was skeptical that so many uninsured people would actually start buying insurance. "We're premising all this on the idea that we'll cross-subsidize older, sicker people with a lot of young healthy people, whom we assume will buy the coverage," he said. "But what if they don't?"
Many of the uninsured in America are in the same economic boat as Mr. Mann. Some 60 percent of the uninsured earn less than 200 percent of the federal poverty level ($21,660 for a single person and $44,100 for a family of four), according to Sara R. Collins, of the Commonwealth Fund, a health care research group. As earnings increase, people are more likely to be insured, experts say.
A recent study by the fund said that about one-third of people who tried to buy health insurance on their own were turned down or charged more because of a medical condition. But three-quarters walked away for other reasons, and most cited price; 60 percent said it was either "difficult" or "impossible" to find an affordable plan, said Ms. Collins, vice president for the fund's Affordable Health Insurance Program.
Jacqui Brownstein, 63, a freelance copy editor and proofreader, said she moved to Lancaster, Pa., from New Jersey in 2004 primarily because health insurance was more affordable there. But she can't afford it anymore; the last time she bought insurance, she paid $4,300 a year, but the rate quoted last year was $5,700. "There was no way I could afford it, so I dropped it," said Ms. Brownstein, a smoker who has Type 2 diabetes and a family history of ovarian cancer.
Premium subsidies, which will be available to people who buy insurance through the exchanges being established, are supposed to address that problem, experts say. A 40-year-old in a medium-cost geographic area who earns $21,660 (200 percent of the federal poverty level) and whose annual premium is $3,500, for example, would receive a subsidy of $2,135 that goes directly to the insurer, while he or she pays $1,365. A family of four with an income of $44,100 would pay $2,778 while the government subsidizes the plan to the tune of $6,656.
The proportion of income people at this level have to pay for insurance is capped at no more than 6.3 percent of their earnings.
As income increases, the subsidy drops; families earning 300 to 400 percent of the federal poverty level are expected to pay up to 9.5 percent of their income, an amount that ranges from $6,284 to $8,379 per year; the federal subsidy is from $3,150 to $1,056. At the same time, however, a provision states that anyone who cannot find a premium that costs less than 8 percent of their income is exempted from the penalty.
It's hard to predict whether the carrots and sticks of subsidies and penalties will suffice to bring people into the system, when there are so many are unemployed or underemployed people, many earning less in today's economy than before and worried about job security and prospects.
From a pure dollars-and-cents point of view, it is cheaper for people just to pay the penalty. Even when fully implemented in 2016, the penalty is limited to no more than 2.5 percent of taxable income, and it starts out even lower, with a penalty of $95 or 1 percent of income in 2014.
"It's hard to analyze because people are making health decisions based on their wallets," said Sara Horowitz, who founded the Freelancers Union, a nonprofit organization that offers health insurance to freelancers.
Monday, April 19, 2010
Sitting Down on the Job: New Data Finds That Patients Are Happier When Doctors Sit Down, Even if They Don't Stay as Long | Earth Times News
Sitting down on the job has its advantages. New data from The University of Kansas Hospital finds that patients perceive doctors who sit down during their hospital room visits stay longer than doctors who stand during the visit ? even when doctors who sit don't stay as long as doctors who stand.
The study found that doctors, when standing, spent an average of one minute, 28 seconds with the patient but were perceived as staying an average time of three minutes and 44 seconds. Conversely, when doctors sat down during their visits, patients perceived them as spending more than five minutes in the room, even though the average sit-down visit was just over one minute -- a shorter amount of time than the stand-up visits. Based on the results of this study, doctors who sat during their visit were perceived by patients as spending 40 percent more time in the room.
"I remember being taught in medical school that you should always sit down when speaking with a patient because it will seem like you are staying in the room longer," says study author Paul M. Arnold, M.D., director of The University of Kansas Hospital's Spinal Cord Injury Center. "Unfortunately, there isn't any data to back up that claim which is why we embarked on this study."
As a result of the increased perceived length of time with the physician, patients are more satisfied with their care and report a better understanding of their condition when the physician sits during the visit. When the physician is seated, 95 percent of patients' post-visit comments are positive. However, when the physician stands, only 61 percent of the patient comments are positive.
When patients think the doctor is in the room longer, they express a better understanding of their condition and greater satisfaction with their care, which can be factors in decreased lengths of stay, decreased costs, improved clinical outcomes and decreased litigation.
Researchers stress that, while sitting can impact patient perception, it does not take the place of good communications skills.
"Communication skills are taught at 65 percent of medical schools across the country, including The University of Kansas," says Dr. Arnold. "This survey provides the exact type of qualitative and quantitative data that we need to support teaching these skills. Taking the time to listen and respond to patient concerns is a significant part of this job. At the end of the day, whether you sit or stand, what's most important is that the patient receives the best possible care."http://www.earthtimes.org/articles/show/sitting-down-on-the-job,1236575.shtml#
Your chances of having the risk factors for heart disease can greatly depend on your ethnic heritage, new Canadian research suggests.
The study, conducted at Ontario's Institute for Clinical Evaluative Sciences (ICES), found that different ethnic groups can develop vastly different heart disease risk factors.
That might mean that "one-size-fits-all" strategies for preventing heart disease and stroke might be ignoring the unique needs of certain ethnic groups, the authors suggest in the article, published in the Canadian Medical Association Journal.
Among the ethnic differences the study found:
- Obesity was five times more prevalent in Caucasian and black Ontario residents than people of Chinese heritage.
- South Asians and blacks in Ontario have twice the risk of developing Type 2 diabetes than Caucasian and Chinese residents.
- Cardiovascular disease (heart disease or stroke) was almost twice as prevalent in South Asians as in Chinese.
- Blacks have a 44 per cent higher incidence of high blood pressure, and South Asians have a 24 per cent higher incidence, as compared to Caucasian Ontario residents.
- Caucasians are almost three times more likely to smoke than Chinese and South Asian groups. Interestingly, rates of smoking in Chinese (8.7 per cent) and South Asian (8.6 per cent) residents of Ontario are significantly lower than in China (28.9 per cent) and India (15.6 per cent).
The study, which looked at more than 165,000 Ontario residents between 1996 and 2007, found that overall, Chinese respondents had the most favourable cardiovascular risk factor profile.
They noted that only 4.3 per cent of the Chinese population reported two or more major cardiovascular risk factors, which include: current smoking, obesity, diabetes, and high blood pressure.
That was followed by South Asians, among whom 7.9 per cent had two or more risk factors. A little over 10 per cent of Caucasian residents had two or more risk factors, while 11.1 per cent of black respondents had two risk factors.
The researchers noted an interesting "Black paradox": Though black residents had a higher prevalence of most cardiovascular risk factors, they had a lower prevalence of heart disease, at just 3.4 per cent.
South Asians had the highest prevalence of heart disease at 5.2 per cent.
Other differences the study noted included:
- Black females have higher prevalence of obesity, diabetes, hypertension and heart disease than Black males.
- Smoking was more common in men than women, but the difference between men and women was much smaller in the Caucasian and Black groups than in the Chinese and South Asian groups.
- Between two-thirds and three-quarters of study participants didn't exercise at least 15 minutes a day. The problem was worst among South Asian men (70 per cent) and women (75 per cent), Chinese men (71 per cent) and women (75 per cent) and Black women (71 per cent).
The study, funded by the Heart and Stroke Foundation of Ontario, is considered the most comprehensive to date to determine health differences among ethnic groups in Canada.
"Although Canada is one of the most ethnically diverse countries in the world, relatively little is known about how Canada's four major ethnic groups differ in their cardiovascular risk profiles," said Maria Chiu, the principal investigator of the study and an ICES Doctoral Fellow.
Dr. Chi-Ming Chow, a cardiologist and Heart & Stroke Foundation of Ontario spokesperson, says it's important that these ethnic differences be highlighted.
"People can actually develop these important risk factors -- these silent killers that may not have any symptoms – at an early age," he told CTV News.
"So many people think ‘I'm fine. I don't need to see a doctor. I'm feeling well.' But they may be hiding all these important risk factors like diabetes, high blood pressure, high cholesterol."
The authors note that there are nearly 2 million people of South Asian, Chinese or Black descent living in Ontario and more than 9 million people of European descent.
And while people of South Asian, Chinese and black ethnic background represent approximately 60 per cent of the world's population, the body of knowledge of cardiovascular risk has been derived mainly from studies conducted in Caucasian populations.
Dr. Marco Di Buono, Director of Research at the Heart and Stroke Foundation of Ontario noted that many of Canada's ethno-cultural communities have unique linguistic and cultural challenges to overcome with respect to improving their heart health.
"We need to address these challenges to ensure the long-term heart health of all Canadians, including new immigrants coming to this country," he said in a statement.http://toronto.ctv.ca/servlet/an/local/CTVNews/20100419/ethnic_health_100419/20100419/?hub=TorontoNewHome