Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting

Context

It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle‐related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands.

Methods

We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints.

Findings

We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost‐effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public.

Conclusions

This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion—in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.

Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

Rationing and Disparities in Health Care: Implications for Radiology Clinical Practice Guidelines

We examine the relationship between the rationing of health care resources and disparities in health care delivery and the specific implications for radiologic resource allocation frameworks such as the ACR Appropriateness Criteria. We explore what rationing is in this context and how it is manifested in radiology. We review how rationing has taken many forms and how rationing has influenced the development of disparities in access and outcomes within health care and specifically within the context of radiology. We describe how the relationship between rationing and health care delivery disparities manifested during the coronavirus disease 2019 pandemic and the corrective measures that were proposed to established rationing frameworks to facilitate more equitable pandemic-related resource distribution. We offer suggestions regarding how such solutions might be brought into radiologic resource allocation schemes to help mitigate disparities in radiologic care in the future.

Themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making in healthcare systems: a scoping review

OBJECTIVE

To identify the key themes for evaluating the quality of initiatives to engage patients and family caregivers in decision-making across the organisation and system domains of healthcare systems.

METHODS

We conducted a scoping review. Seven databases of journal articles were searched from their inception to June 2019. Eligible articles were literature reviews published in English and provided useful information for determining aspects of engaging patients and family caregivers in decision-making to evaluate. We extracted text under three predetermined categories: structure, process and outcomes that were adapted from the Donabedian conceptual framework. These excerpts were then independently open-coded among four researchers. The subsequent themes and their corresponding excerpts were summarised to provide a rich description of each theme.

RESULTS

Of 7747 unique articles identified, 366 were potentially relevant, from which we selected the 42 literature reviews. 18 unique themes were identified across the three predetermined categories. There were six structure themes: engagement plan, level of engagement, time and timing of engagement, format and composition, commitment to support and environment. There were four process themes: objectives, engagement approach, communication and engagement activities. There were eight outcome themes: decision-making process, stakeholder relationship, capacity development, stakeholder experience, shape policy/service/programme, health status, healthcare quality, and cost-effectiveness.

CONCLUSIONS

The 18 themes and their descriptions provide a foundation for identifying constructs and selecting measures to evaluate the quality of initiatives for engaging patients and family caregivers in healthcare system decision-making within the organisation and system domains. The themes can be used to investigate the mechanisms through which relevant initiatives are effective and investigate their effectiveness.

Quality of life in elderly ICU survivors before the COVID-19 pandemic: a systematic review and meta-analysis of cohort studies

OBJECTIVES

The influence of age on intensive care unit (ICU) decision-making is complex, and it is unclear if it is based on expected subjective or objective patient outcomes. To address recent concerns over age-based ICU decision-making, we explored patient-assessed quality of life (QoL) in ICU survivors before the COVID-19 pandemic.

DESIGN

A systematic review and meta-analysis of cohort studies published between January 2000 and April 2020, of elderly patients admitted to ICUs.

PRIMARY AND SECONDARY OUTCOME MEASURES

We extracted data on self-reported QoL (EQ-5D composite score), demographic and clinical variables. Using a random-effect meta-analysis, we then compared QoL scores at follow-up to scores either before admission, age-matched population controls or younger ICU survivors. We conducted sensitivity analyses to study heterogeneity and bias and a qualitative synthesis of subscores.

RESULTS

We identified 2536 studies and included 22 for qualitative synthesis and 18 for meta-analysis (n=2326 elderly survivors). Elderly survivors' QoL was significantly worse than younger ICU survivors, with a small-to-medium effect size (d=0.35 (-0.53 and -0.16)). Elderly survivors' QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (-0.44 and -0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (-0.43 and 0.00)). Mortality rates and length of follow-up partly explained heterogeneity. Reductions in QoL seemed primarily due to physical health, rather than mental health items.

CONCLUSIONS

The results suggest that the proportionality of age as a determinant of ICU resource allocation should be kept under close review and that subjective QoL outcomes should inform person-centred decision -aking in elderly ICU patients.

PROSPERO REGISTRATION NUMBER

CRD42020181181.

COVID-19: The South African experience

The coronavirus disease-2019 pandemic affected the countries differently. South Africa is a middle-income country with a struggling economy and a resource-constrained public healthcare system. Three aspects of the pandemic in South Africa are examined, the lockdown and its effect on personal freedoms, how health care resources were used and the novel stratification of health workers into vulnerability categories. It is a perspective written after experiencing the first pandemic peak in 2020.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans

BACKGROUND

Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators.

RESEARCH QUESTION

How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans?

STUDY DESIGN AND METHODS

This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration.

RESULTS

Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy.

INTERPRETATION

Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

A systematic review of direct preference measurements in health states treated with plastic surgery

One way to compare health care needs and outcomes on common scales is by estimating the strength of preferences or willingness-to-pay (WTP). The aim of this study was to review directly measured preference values and WTP estimates for health states treated by plastic surgery. The included articles had to meet the criteria defined in the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type). Relevant databases were searched using predetermined strings. Data were extracted in a standardised manner. Included studies were appraised according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for rating the importance of outcomes. In total, 213 abstracts were retrieved. Of these, 179 did not meet the inclusion criteria and were excluded, leaving 34 studies in the review. The risk of bias was considered moderate in four studies and serious in the rest. The overall certainty of evidence for directly measured preference values and WTP estimates for health states treated by plastic surgery is low (Grade ƟƟОО). The lowest preference scores were generally elicited for facial defects/anomalies and the highest for excess skin after massive weight loss. Scientific knowledge about preferences and the resulting health gains might play an essential role in deciding which procedures should be considered for public funding or rather rationed within the system. Better quality studies are required to allow for such applications.

Oxygen and Mortality in COVID-19 Pneumonia: A Comparative Analysis of Supplemental Oxygen Policies and Health Outcomes Across 26 Countries

Introduction: Hypoxia is the main cause of morbidity and mortality in COVID-19. During the COVID-19 pandemic, some countries have reduced access to supplemental oxygen, whereas other nations have maintained and even improved access to supplemental oxygen. We examined whether variation in the nationally determined oxygen guidelines had any association with national mortality rates in COVID-19.

Methods: Three independent investigators searched for, identified, and extracted the nationally recommended target oxygen levels for the commencement of oxygen in COVID-19 pneumonia from the 29 worst affected countries. Mortality estimates were calculated from three independent sources. We then applied both parametric (Pearson's R) and non-parametric (Kendall's Tau B) tests of bivariate association to determine the relationship between case fatality rate (CFR) and target SpO₂, and also between potential confounders and CFR.

Results: Of the 26 nations included, 15 had employed conservative oxygen strategies to manage COVID-19 pneumonia. Of them, Belgium, France, USA, Canada, China, Germany, Mexico, Spain, Sweden, and the UK guidelines advised commencing oxygen when oxygen saturations (SpO₂) fell to 91% or less. A statistically significant correlation was found between SpO₂ and CFR both parametrically (R = −0.53, P < 0.01) and non-parametrically (−0.474, P < 0.01).

Conclusion: Our study highlights the disparity in oxygen provision for COVID-19 patients between the nations analysed. In those nations that pursued a conservative oxygen strategy, there was an association with higher national mortality rates. We discuss the potential reasons for such an association.

Ruthless Utilitarianism? COVID-19 State Triage Protocols May Subject Patients to Racial Discrimination and Providers to Legal Liability

As the coronavirus pandemic intensified, many communities in the United States experienced shortages of ventilators, intensive care beds, and other medical supplies and treatments. Currently, there is no single national response to provide guidance on allocation of scarce health care resources. Accordingly, states have formulated various "triage protocols" to prioritize those who will receive care and those who may not have the same access to health care services when the population demand exceeds the supply. Triage protocols address general concepts of "fairness" under accepted medical ethics rules and the consensus is that limited medical resources "should be allocated to do the greatest good for the greatest number of people."1 The actual utility of this utilitarian ethics approach is questionable, however, leaving many questions about what is "fair" unanswered. Saving as many people as possible during a health care crisis is a laudable goal but not at the expense of ignoring patients's legal rights, which are not suspended during the crisis. This Article examines the triage protocols from six states to determine whose rights are being recognized and whose rights are being denied, answering the pivotal question: If there is potential for disparate impact of facially neutral state triage protocols against Black Americans and other ethnic groups, is this legally actionable discrimination? This may be a case of first impression for the courts to resolve."[B]lack Americans are 3.5 times more likely to die of COVID-19 than [W]hite Americans … . Latinx people are almost twice as likely to die of the disease, compared with [W]hite people." 2 "Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism … . HHS is committed to leaving no one behind during an emergency, and this guidance is designed to help health care providers meet that goal." - Roger Severino, Office of Civil Rights Director, U.S. Department of Health and Human Services. 3.

Association of socioeconomic status with medical assistance in dying: a case-control analysis

OBJECTIVES

Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints.

DESIGN

Population-based case-control study of adults who died.

SETTING

Ontario, Canada, between 1 June 2016 and 1 June 2019.

PATIENTS

Patients receiving palliative care under universal insurance with no user fees.

EXPOSURE

Patient's socioeconomic status identified using standardised quintiles.

MAIN OUTCOME MEASURE

Whether the patient received medical assistance in dying.

RESULTS

A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design.

CONCLUSIONS

Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

Prognostic model to identify and quantify risk factors for mortality among hospitalised patients with COVID-19 in the USA

OBJECTIVES

To develop a prognostic model to identify and quantify risk factors for mortality among patients admitted to the hospital with COVID-19.

DESIGN

Retrospective cohort study. Patients were randomly assigned to either training (80%) or test (20%) sets. The training set was used to fit a multivariable logistic regression. Predictors were ranked using variable importance metrics. Models were assessed by C-indices, Brier scores and calibration plots in the test set.

SETTING

Optum de-identified COVID-19 Electronic Health Record dataset including over 700 hospitals and 7000 clinics in the USA.

PARTICIPANTS

17 086 patients hospitalised with COVID-19 between 20 February 2020 and 5 June 2020.

MAIN OUTCOME MEASURE

All-cause mortality while hospitalised.

RESULTS

The full model that included information on demographics, comorbidities, laboratory results, and vital signs had good discrimination (C-index=0.87) and was well calibrated, with some overpredictions for the most at-risk patients. Results were similar on the training and test sets, suggesting that there was little overfitting. Age was the most important risk factor. The performance of models that included all demographics and comorbidities (C-index=0.79) was only slightly better than a model that only included age (C-index=0.76). Across the study period, predicted mortality was 1.3% for patients aged 18 years old, 8.9% for 55 years old and 28.7% for 85 years old. Predicted mortality across all ages declined over the study period from 22.4% by March to 14.0% by May.

CONCLUSION

Age was the most important predictor of all-cause mortality, although vital signs and laboratory results added considerable prognostic information, with oxygen saturation, temperature, respiratory rate, lactate dehydrogenase and white cell count being among the most important predictors. Demographic and comorbidity factors did not improve model performance appreciably. The full model had good discrimination and was reasonably well calibrated, suggesting that it may be useful for assessment of prognosis.

UK advanced practice nurses' experiences of the COVID-19 pandemic: a mixed-methods cross-sectional study

OBJECTIVE

The aim of the study was to understand the experiences of advanced practice nurses (APNs) in the UK during the 2020 COVID-19 pandemic, particularly in relation to safety, shortages and retention.

DESIGN

A cross-sectional, mixed-methods survey.

SETTING

APNs in any UK setting.

PARTICIPANTS

The survey was sent to an existing UK-wide cohort of APNs. 124 APNs responded (51%).

RESULTS

UK-based APNs in this study reported shortages of staff (51%) and personal protective equipment (PPE) (68%) during the first 3 months of the coronavirus outbreak. Almost half (47%) had considered leaving their job over the same 3 months. Despite difficulties, there were reports of positive changes to working practice that have enhanced care.

CONCLUSION

UK APNs report COVID-19-related shortages in staff and equipment across primary and secondary care and all regions of the UK. Shortages of PPE during a pandemic are known to be a factor in the development of mental health sequelae as well as a risk factor for increased turnover and retention issues. Half of APNs surveyed were considering a change in job. The UK risks a further crisis in staff morale and retention if this is not acknowledged and addressed. APNs also expressed concern about patients not receiving routine care as many specialties closed or reduced working during the crisis. However, there were also many examples of good practice, positive changes and innovation.

Public Perspectives on Anti-Diabetic Drugs: Exploratory Analysis of Twitter Posts

Background

Diabetes mellitus is a major global public health issue where self-management is critical to reducing disease burden. Social media has been a powerful tool to understand public perceptions. Public perception of the drugs used for the treatment of diabetes may be useful for orienting interventions to increase adherence.

Objective

The aim of this study was to explore the public perceptions of anti-diabetic drugs through the analysis of health-related tweets mentioning such medications.

Methods

This study uses an infoveillance social listening approach to monitor public discourse using Twitter data. We coded 4000 tweets from January 1, 2019 to October 1, 2019 containing key terms related to anti-diabetic drugs by using qualitative content analysis. Tweets were coded for whether they were truly about an anti-diabetic drug and whether they were health-related. Health-related tweets were further coded based on who was tweeting, which anti-diabetic drug was being tweeted about, and the content discussed in the tweet. The main outcome of the analysis was the themes identified by analyzing the content of health-related tweets on anti-diabetic drugs.

Results

We identified 1664 health-related tweets on 33 anti-diabetic drugs. A quarter (415/1664) of the tweets were confirmed to have been from people with diabetes, 17.9% (298/1664) from people posting about someone else, and 2.7% (45/1664) from health care professionals. However, the role of the tweeter was unidentifiable in two-thirds of the tweets. We identified 13 themes, with the health consequences of the cost of anti-diabetic drugs being the most extensively discussed, followed by the efficacy and availability. We also identified issues that patients may conceal from health care professionals, such as purchasing medications from unofficial sources.

Conclusions

This study uses an infoveillance approach using Twitter data to explore public perceptions related to anti-diabetic drugs. This analysis gives an insight into the real-life issues that an individual faces when taking anti-diabetic drugs, and such findings may be incorporated into health policies to improve compliance and efficacy. This study suggests that there is a fear of not having access to anti-diabetic drugs due to cost or physical availability and highlights the impact of the sacrifices made to access anti-diabetic drugs. Along with screening for diabetes-related health issues, health care professionals should also ask their patients about any non–health-related concerns regarding their anti-diabetic drugs. The positive tweets about dietary changes indicate that people with type 2 diabetes may be more open to self-management than what the health care professionals believe.

The Effect of a Name-Based Mask Rationing Plan in Taiwan on Public Anxiety Regarding a Mask Shortage During the COVID-19 Pandemic: Observational Study

Background

The COVID-19 pandemic is a severe global health crisis. Wearing a mask is a straightforward action that can be taken, but shortage of stock and equity of allocation were important issues in Taiwan. Furthermore, increased anxiety leading to the stockpiling of masks has been common during the pandemic.

Objective

We aim to summarize the name-based mask rationing plan implemented in Taiwan and explore the public’s perceived anxiety about mask shortages.

Methods

The government of Taiwan took action to control the supply and allocation of face masks. We summarize the timeline and important components of the mask rationing plan. A survey that aimed to investigate the overall response to the mask rationing plan was answered by 44 participants.

Results

The mask rationing plan was implemented in late January 2020. Daily production capacity was increased from 2 million masks to 16 million masks in April 2020. People could buy 9 masks in 14 days by verification via their National Health Insurance card. Digital face mask availability maps were created. Moreover, the mask plan safeguarded the purchase of masks and resulted in decreased anxiety about a mask shortage (4.05 [SD 1.15] points; 72.7% [n=32] of participants answered “agree” or “strongly agree”). The majority of people felt that the mask plan was satisfactory (4.2 [SD 0.92] points; 79.5% [n=35] of participants answered “agree” or “strongly agree”).

Conclusions

We found that the unique name-based mask rationing plan allowed for control of the production and supply of masks, and contributed to the appropriate allocation of masks. The mask rationing plan not only provided the public with physical protection, but also resulted in reduced anxiety about mask shortages during the pandemic.

Room to Breathe: The Impact of Oxygen Rationing on Health Outcomes in SARS-CoV2

As the primary surge of coronavirus disease 2019 (COVID-19) wanes in many countries, it is important to reconsider best practice. More cases, probably the majority of cases, are yet to come. Hopefully, during this next phase, we will have more time, more resources, and more experience from which to affect better outcomes. Here, we examine the compromised oxygen strategy that many nations followed. We explore the evidence related to such strategies and discuss the potential mortality impact of delaying oxygen treatment in COVID-19 pneumonia.

[Analysis of the application of lean manufacturing tools in the dental service]

THE AIM OF THE STUDY

Synchronization of methods and tools of lean manufacturing (BP) and the possibility of their practical application in the organization of the dental service.

MATERIALS AND METHODS

The methods of synthesis and analysis of data from scientific sources and regulatory documents and the empirical method were used to study the use of various BP tools in the management of dental organizations.

RESULTS

In the course of studying the possibility of using BP tools in the dental service, their systematization was carried out on the basis of the principle of use in dental medical organizations.

CONCLUSION

The use of BP tools in the management of dental organizations allows them to correspond to a certain extent to the new model of a medical organization.

Utilisation, expenditure and cost-effectiveness of cystic fibrosis drugs in Ireland: a retrospective analysis of a national pharmacy claims database

OBJECTIVES

To determine the use and expenditure associated with cystic fibrosis (CF) modulator therapies in Ireland since their reimbursement in 2013.

DESIGN

A retrospective analysis of a national drug claims database.

SETTING

The data included in this study are nationally representative (Ireland).

PARTICIPANTS

Data on all persons receiving CF modulator therapies were included.

METHODS

We obtained national claims data for CF therapies from the Health Service Executive's Primary Care Reimbursement Service. We determined the use and expenditure associated with CF therapies from January 2012 to March 2020.

RESULTS

The increased prescribing of CF modulator therapies was associated with an approximate fivefold increase in expenditure from €23 million in 2013 to €113 million in 2019. Many patients who initiated lumacaftor/ivacaftor in 2017 went on to receive symptomatic therapies, and subsequently initiated tezacaftor/ivacaftor in 2019.

CONCLUSION

Despite none of these modulator therapies demonstrating value for money when subjected to health technology assessment, the associated Irish expenditure reached €113 million in 2019 alone.

Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study

BACKGROUND

Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches.

OBJECTIVES

To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch.

DESIGN

A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted.

SETTING

The secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period.

PARTICIPANTS

There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses.

MAIN OUTCOME MEASURES

Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients.

RESULTS

The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005).

CONCLUSION

Secondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.

Unmet care needs of older people: A scoping review

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

Evaluating underpinning, complexity and implications of ethical situations in humanitarian operations: qualitative study through the lens of career humanitarian workers

INTRODUCTION

Data regarding underpinning and implications of ethical challenges faced by humanitarian workers and their organisations in humanitarian operations are limited.

METHODS

We conducted comprehensive, semistructured interviews with 44 experienced humanitarian aid workers, from the field to headquarters, to evaluate and describe ethical conditions in humanitarian situations.

RESULTS

61% were female; average age was 41.8 years; 500 collective years of humanitarian experience (11.8 average) working with diverse major international non-governmental organisations. Important themes included; allocation schemes and integrity of the humanitarian industry, including resource allocation and fair access to and use of services; staff or organisational competencies and aid quality; humanitarian process and unintended consequences; corruption, diversion, complicity and competing interests, and intentions versus outcomes; professionalism and interpersonal and institutional responses; and exposure to extreme inequities and emotional and moral distress. Related concepts included broader industry context and allocations; decision-making, values, roles and sustainability; resource misuse at programme, government and international agency levels; aid effectiveness and utility versus futility, and negative consequences. Multiple contributing, confounding and contradictory factors were identified, including context complexity and multiple decision-making levels; limited input from beneficiaries of aid; different or competing social constructs, values or sociocultural differences; and shortcomings, impracticality, or competing philosophical theories or ethical frameworks.

CONCLUSIONS

Ethical situations are overarching and often present themselves outside the exclusive scope of moral reasoning, philosophical views, professional codes, ethical or legal frameworks, humanitarian principles or social constructivism. This study helped identify a common instinct to uphold fairness and justice as an underlying drive to maintain humanity through proximity, solidarity, transparency and accountability.

Exploration of rural physicians' lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study

OBJECTIVES

Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.

DESIGN

A hermeneutic phenomenological study.

SETTING

An international rural medicine conference.

PARTICIPANTS

All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited.

INTERVENTIONS

Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group.

PRIMARY OUTCOME MEASURE

An understanding of the lived experiences of clinical courage.

RESULTS

Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one's own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again.

CONCLUSION

This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

Healthcare Rationing Cutoffs and Sorites Indeterminacy

Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as "beneficial," "effective," or even "futile," the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient Greek philosophical conundrum known as the "sorites paradox." I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing).

[Chemical food safety: development of methodological and regulatory base]

The review presents the results of studies carried out in the Federal Research Centre of Nutrition and Biotechnology in the direction of food toxicology, the purpose of which was to improve the risk assessment methodology, substantiate hygienic regulations for the content of chemical contaminants in foodstuffs and develop methods for their detection and quantitative determination. New challenges and problems associated with the control and regulation of chemical contaminants in foods are associated, firstly, with the identification of previously unrecognized chemical factors harmful to human health, and, secondly, are caused by the progress of technologies, accompanied by the emergence of new sources of nutrients and methods of processing foodstuffs, which, along with many benefits and advantages, creates new potential risks to consumer health. Among the priority chemical pollutants, which should be mentioned currently as objects of improved regulation and control methods, are toxic elements (organic and inorganic forms of arsenic, mercury, nickel), veterinary drugs, phycotoxins, phytotoxins, new mycotoxins, various forms of polychlorinated biphenyls and polycyclic aromatic hydrocarbons, biologically active substances of plant origin, concentrated during the production of extracts, as well as so-called technological contaminants, food additives, residual amounts of technological aids. An independent problem is the assessment of risks from nanoparticles and nanomaterials used in the production of foodstuffs, as well as enzyme preparations and food ingredients produced with the help of genetically modified microorganisms. The system of toxicological and hygienic assessment and control of chemical contaminants in foodstuffs operating in Russia is constantly being improved on the basis of new scientific data to substantiate the permissible levels of their content in products and new methods of analysis. The results obtained are reflected in the regulatory documents of the Russian Federation and the Eurasian Economic Union.