Open Access to essential health care information

Open Access publishing is a valuable resource for the synthesis and distribution of essential health care information. This article discusses the potential benefits of Open Access, specifically in terms of Low and Middle Income (LAMI) countries in which there is currently a lack of informed health care providers - mainly a consequence of poor availability to information. We propose that without copyright restrictions, Open Access facilitates distribution of the most relevant research and health care information. Furthermore, we suggest that the technology and infrastructure that has been put in place for Open Access could be used to publish download-able manuals, guides or basic handbooks created by healthcare providers in LAMI countries.     

Oral health care in long‐term care facilities for elderly people in southern Brazil: a conceptual framework

doi:10.1111/j.1741‐2358.2009.00280.x
Oral health care in long‐term care facilities for elderly people in southern Brazil: a conceptual framework Objective: To present a theoretical model for understanding oral health care for the elderly in the context of long‐term care institutions (LTCI). Methods: Open‐ended individual interviews were conducted with the elderly residing in LTCI, their carers, nursing technicians and nurses, directors of care, dental surgeons and managers of public health services. A grounded theory methodological approach was adopted for data collection and analysis. Results: The emerging core category revealed a basic social process: ‘Promoting oral health care for the elderly based on the context of LTCI’. This process was composed of two contradicting yet correlated aspects: the oral health care does not minimise the poor oral epidemiological condition, and at the same time, there was a continued improvement in the oral care expressed by better care practices. These aspects were related to the: attribution of meaning to oral health, social determination of oral health, the ageing process, interactions established in the oral health care practices, oral health care management in LTCI, inclusion of oral health care into the political–organisational dimension and possibility of conjecturing better oral health care practices. Conclusion: The core concept of ‘Promotion of oral health care for elderly people based on the context of LTCI’ is capable of explaining the variations in the structure and process of LTCI, as well as in helping to understand the meaning of the oral health care practices for the institutionalised elderly.     

Measuring the health of nations: analysis of mortality amenable to health care

Objective To assess whether and how the rankings of the world''s health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.Design Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).Main outcome measure Age standardised mortality from causes amenable to health careSetting 19 countries belonging to the Organisation for Economic Cooperation and Development.Results Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.Conclusion The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.     

Ionic currents in cardiac muscle: a framework for glycoside action.

This paper briefly reviews the current state of understanding of cardiac excitation--contraction coupling and its relation to glycoside action. Evidence that inotropic action of glycosides might result from increased influx of Ca2+ during action potential is reviewed. Recent voltage clamp studies that show little if any direct effect on Ca2+ influx during the action potential are cited. It is suggested that the primary inotropic effects derive from altered ionic exchange mechanisms secondary to inhibition of Na+,K+-ATPase. The role of ionic currents in glycoside toxicity is considered, with discussion of a dynamic, depolarizing current that appears shortly after action potential. This current is apparently an inward movement of positive ions that is strongly mediated by extracellular Ca2+ levels. It is noted that such spontaneous depolarizations of the membrane have been observed in several other circumstances where strong positive inotropism has been induced. The conclusion is reached that membrane ionic currents probably play only a secondary role in glycoside inotropism and in many of the toxic effects.     

Quality of oral health services in residential care: towards an evaluation framework

Background: There is widespread neglect of oral healthcare, and uncertainty about how best to organise and evaluate the impact of oral health services in long‐term care (LTC) facilities. Consequently, there is need for an evaluation framework to improve and account for the quality of oral healthcare in the facilities. Objectives: This paper: (i) identifies basic concepts of quality of care and evaluation in healthcare; (ii) reviews the methods used to evaluate the operation and effectiveness of oral healthcare in LTC facilities and (iii) recommends change to assure oral health‐related quality and accountability for frail elders. Method: A literature review provided insights to the theoretical basis and practical applications for assessing the quality of healthcare relevant to oral healthcare for frail elders. Results: Oral health‐related programmes in LTC facilities could be improved by using a combination of quality assurance and health programme evaluation that: (i) engages everyone involved; (ii) seeks multiple attributes of quality; (iii) evaluates the structure, process or activities, and outcome of the oral health programme; (iv) uses formative and summative methods to provide both quantitative and qualitative evidence of care and (v) transfers new knowledge for appropriate consideration and action. Conclusions: This theoretical framework can be applied in dentistry in LTC to provide an assessment model specific to oral healthcare for frail elders in residential care.     

Access to health care among status Aboriginal people with chronic kidney disease

Background

Ethnic disparities in access to health care and health outcomes are well documented. It is unclear whether similar differences exist between Aboriginal and non-Aboriginal people with chronic kidney disease in Canada. We determined whether access to care differed between status Aboriginal people (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease.

Methods

We identified 106 511 non-Aboriginal and 1182 Aboriginal patients with chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m²). We compared outcomes, including hospital admissions, that may have been preventable with appropriate outpatient care (ambulatory-care–sensitive conditions) as well as use of specialist services, including visits to nephrologists and general internists.

Results

Aboriginal people were almost twice as likely as non-Aboriginal people to be admitted to hospital for an ambulatory-care–sensitive condition (rate ratio 1.77, 95% confidence interval [CI] 1.46–2.13). Aboriginal people with severe chronic kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m²) were 43% less likely than non-Aboriginal people with severe chronic kidney disease to visit a nephrologist (hazard ratio 0.57, 95% CI 0.39–0.83). There was no difference in the likelihood of visiting a general internist (hazard ratio 1.00, 95% CI 0.83–1.21).

Interpretation

Increased rates of hospital admissions for ambulatory-care–sensitive conditions and a reduced likelihood of nephrology visits suggest potential inequities in care among status Aboriginal people with chronic kidney disease. The extent to which this may contribute to the higher rate of kidney failure in this population requires further exploration.Ethnic disparities in access to health care are well documented;^1,2 however, the majority of studies include black and Hispanic populations in the United States. The poorer health status and increased mortality among Aboriginal populations than among non-Aboriginal populations,^3,4 particularly among those with chronic medical conditions,^5,6 raise the question as to whether there is differential access to health care and management of chronic medical conditions in this population.The prevalence of end-stage renal disease, which commonly results from chronic kidney disease, is about twice as common among Aboriginal people as it is among non-Aboriginal people.^7,8 Given that the progression of chronic kidney disease can be delayed by appropriate therapeutic interventions^9,10 and that delayed referral to specialist care is associated with increased mortality,^11,12 issues such as access to health care may be particularly important in the Aboriginal population. Although previous studies have suggested that there is decreased access to primary and specialist care in the Aboriginal population,^13–15 these studies are limited by the inclusion of patients from a single geographically isolated region,¹³ the use of survey data,¹⁴ and the inability to differentiate between different types of specialists and reasons for the visit.¹⁵In addition to physician visits, admission to hospital for ambulatory-care–sensitive conditions (conditions that, if managed effectively in an outpatient setting, do not typically result in admission to hospital) has been used as a measure of access to appropriate outpatient care.^16,17 Thus, admission to hospital for an ambulatory-care–sensitive condition reflects a potentially preventable complication resulting from inadequate access to care. Our objective was to determine whether access to health care differs between status Aboriginal (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease. We assess differences in care by 2 measures: admission to hospital for an ambulatory-care–sensitive condition related to chronic kidney disease; and receipt of nephrology care for severe chronic kidney disease as recommended by clinical practice guidelines.¹⁸     

Access to health: women's status and utilization of maternal health services in Nepal

With the objective of reducing maternal and neonatal mortality, the Safe Motherhood Program was implemented in Nepal in 1997. It was launched as a priority programme during the ninth five-year plan period, 1997-2002, with the aim of increasing women's access to health care and raising their status. This paper examines the association of access to health services and women's status with utilization of prenatal, delivery, and postnatal care during the plan period. The 1996 Nepal Family Health Survey and the 2001 Nepal Demographic and Health Survey data were pooled and the likelihood of women's using maternal health care was examined in 2001 in comparison with 1996. Multiple logistic regression analysis indicates that the utilization of maternal health services increased over the period. Programme interventions such as outreach worker's visits, radio programmes on maternal health, maternal health information disseminated through various mass media sources and raising women's status through education were able to explain the observed change in utilization. Health worker visits and educational status of women showed a large association, but radio programmes and other mass media information were only partially successful in increasing use of maternal health services. Socioeconomic and demographic variables such as household economic status, number of living children and place of residence showed stronger association with use of maternal health services then did intervention programmes.     

Marginal analysis in practice: an alternative to needs assessment for contracting health care.

Prioritising health care services on the basis of total needs can lead to inefficient use of resources. A better option is to determine priorities by marginal analysis, which examines the effects of altering the existing balance of expenditure between health care programmes. Resources to support investment are released from disinvestments-that is, the strategy is resource neutral. Thus an increase in total health benefits is achieved independent of any gains that may result from increased spending on health. In 1989 the Welsh Health Planning Forum identified 10 health gain areas, outlining within each one where further investment was likely to produce health gains and where disinvestment might be considered. All Welsh districts then attempted, with varying degrees of success, to produce a resource neutral strategy. Mid Glamorgan further explored the possibility of using marginal analysis in producing its strategy and influencing its policy for contracting. Working groups for most health gain areas each proposed 10 programmes for investment and a further 10 for disinvestment, which were then evaluated by a core evaluation team. In the case of maternal and child health the team dropped 10 of the 20 proposals. The remainder were considered by the health authority, which dropped a further proposal. Nine of the original 20 proposals thus formally became policy for 1995.