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Biomedical subjects

R B Deber

Publications and source records attributed to R B Deber.

45 records · Page 3Linked to original sources
PubMed1984

The Canadian health care system: an overview.

Although health care is a provincial responsibility in Canada, universal hospital insurance was fully adopted by 1961; universal medical insurance followed 10 years later. Each province enacted universal insurance after the federal government offered to pay 50% of provincial hospital and medical care costs. Hospital insurance had wide public and provider support but universal medical care insurance was opposed by organized medicine. The federal government soon realized that it had no control over total expenditures and no mechanisms for controlling costs. In 1977 it enacted Bill C-37 which limited total federal contributions and made those contributions independent of provincial health care expenditures so that increased costs had to be met by the provinces. Since private health care insurance for universal benefits is prohibited by the federal terms of reference for health insurance, the provinces must raise the money by taxes and (in some provinces) premiums. Although prohibited by the terms of reference of the universal program, some provinces have adopted hospital user fees and are allowing their physicians to bill patients in excess of provincial fee schedules. The 1980s have seen increased confrontations between the federal and provincial governments and between the provinces and their providers. The issues are cost containment and control of the system. The provinces have two broad options. The first is more private funding through private insurance and user fees. The proposed new Canada Health Act will probably prohibit such charges. A second option involves greater control and management of the system by the provinces; this has already occurred in Quebec. Greater control is vigorously opposed by physicians and hospitals. The Canadian solution to health insurance problems in the past has been moderation. Extreme moves in either direction would represent a break with tradition, but they may prove to be unavoidable.

Canada↗
PubMed1982

Why is the number of pregnancies among teenagers decreasing?

The issue of pregnancy among adolescent women has received considerable attention from the media. Contrary to common belief, both the numbers and the rates of such pregnancies, even when data on abortion are included, have been declining. Patterns of contraception may account for some of the decrease; however, more study is required. In the past, unmarried teenagers who became pregnant either got married or put the baby up for adoption. Now they can either have an abortion or keep the baby. Solutions to the problems of pregnancy among teenagers must therefore be addressed to these altered social consequences rather than to misleading comments about "epidemics", with their suggestion of increased rates of pregnancy.

Abortion, Therapeutic↗
PubMedDate not supplied

The determinants of treatment choice in end-stage renal disease: can we generalize about decision making from specific studies?

Practitioner judgments about treatments for hypothetical end-stage renal disease patients were examined by two mailed surveys. It was hypothesized that treatment choice was a function of four hierarchically arranged sets of factors: disease- and treatment-specific, patient-specific, environment- and institution-specific, and practitioner-specific. The first survey identified six vignettes for which the case-specific factors alone did not yield a generally accepted treatment decision. These six cases were used in the second survey, whose results are reported here. Practitioner-specific characteristics were found to be only weakly related to treatment choice. Guttman scale analysis showed no significant practitioner propensity to use any given treatment. Instead, the number of colleagues in a respondent's renal unit picking a given therapy for a given patient was the strongest predictor of an individual's choice. Contextual factors--clinical details of the case and decision rules within the institution--appeared to overwhelm provider-specific tendencies; characteristics of the decision generally outweighed characteristics of the decision maker. This framework of factors may be useful for analyzing inter-provider variation. Consequences for certain approaches to the study of decision making (especially single-site studies and regression-based models) are noted.

Canada↗
PubMedDate not supplied

Using explicit decision rules to manage issues of justice, risk, and ethics in decision analysis: when is it not rational to maximize expected utility?

Concepts of justice, risk, and ethics can be merged with decision analysis by requiring the analyst to specify explicity a decision rule or sequence of rules. Decision rules are categorized by whether they consider: 1) aspects of outcome distributions beyond central tendencies; 2) probabilities as well as utilities of outcomes; and 3) means as well as ends. This formulation suggests that distribution-based decision rules could address both risk (for an individual) and justice (for the population). Rational choice under risk if choices are one-time only (vs. repeated events) or if one branch contains unlikely but disastrous outcomes might ignore probability information. Incorporating risk attitude into decision rules rather than utilities could facilitate use of multiattribute approaches to measuring outcomes. Certain ethical concerns could be addressed by prior specification of rules for allowing particular branches. Examples, including selection of polio vaccine strategies, are discussed, and theoretical and practical implications of a decision rule approach noted.

Beneficence↗
PubMedDate not supplied

Assessment of Ontario's Geriatric Preventive Dentistry Program.

Ontario's Geriatric Preventive Dentistry Program (mandated under the Health Protection and Promotion Act) is assessed using the rational comprehensive approach. Policy options are examined, taking into account population characteristics, the nature of the health problem, current service delivery policy and resources, and barriers to access. Examining the 1974 Task Force recommendations, sets of draft guidelines issued in 1982, 1983, and 1984, and the revised 1985 guidelines as implemented, one can note changes in the benefits offered and in eligibility for coverage. The final program appears to be largely a symbolic policy response, which is unlikely to have major implications for either efficiency or community effectiveness. Implications of the current program, including the possibility it may be a precursor to more effective policies, are noted.

Aged↗
PubMedDate not supplied

Public health in Canada: a comparative study of six provinces.

PURPOSE: To describe the public health systems and their projected futures in six provinces in the context of two developments: 1) the emerging discourse on population health and 2) the trend toward regionalization of the health care system. METHODS: Telephone interviews with key informants and key document review. RESULTS AND CONCLUSIONS: Communicable disease control and health protection are currently the "core businesses" of public health; the population health discourse has not resulted in mandated programming. The reality is a retrenchment of public health scope during a time that should be considered conducive to expansion. Only Ontario has not regionalized its health care system, although public health is already delivered regionally. Alberta, Saskatchewan and Manitoba have either evolved or are evolving toward an integrated health system. There were concerns about the potential impact on public health identity and funding of this "vertical integration". Regionalization of public health may result in units that are too small to support adequate local expertise and may jeopardize development and enforcement of province-wide programs.

Canada↗