The paradox of health care

Vitamin D/Bone Mineral Density and Triglyceride Paradoxes Seen in African Americans: A Cross-Sectional Study and Review of the Literature

Vitamin D is known to have a positive effect on bone health. Despite the greater frequency of vitamin D deficiency in African Americans (AA), they have a higher bone mineral density (BMD) compared to whites, demonstrating a disconnect between BMD and vitamin D levels in AA. Another intriguing relationship seen in AA is the triglyceride (TG) paradox, an unusual phenomenon in which a normal TG status is observed even when patients house conditions known to be characterized by high TG levels, such as Type II diabetes. To the best of our knowledge, no study has examined whether these two paradoxical relationships exist simultaneously in AA subjects with Type II diabetes. In this study, we compared levels of blood markers, including HbA1c, TG, and vitamin D, measured as serum 25-hydroxyvitamin D [25(OH)VD] µM/mL, [25(OH)VD]/TG, calcium, and BMD in AA (n = 56) and white (n = 26) subjects with Type II diabetes to see whether these relationships exist concurrently. We found that AA subjects had significantly lower TG and [25(OH)VD] levels and a significantly higher BMD status compared to white subjects, even when the ages, BMI, duration of diabetes, HbA1c, and calcium levels were similar between the two groups. This demonstrates that these two paradoxical relationships exist simultaneously in Type II diabetic AA subjects. In addition to these findings, we discuss the current hypotheses in the literature that attempt to explain why these two intriguing relationships exist. This review also discusses four novel hypotheses, such as altered circulating levels and the potential role of estrogen and hydrogen sulfide on BMD and HMG-CoA reductase as a possible contributor to the TG paradox in AA subjects. This manuscript demonstrates that there are still many unanswered questions regarding these two paradoxical relationships and further research is needed to determine why they exist and how they can be implemented to improve healthcare.

The role of philosophy and ethics at the edges of medicine

BACKGROUND

The edge metaphor is ubiquitous in describing the present situation in the world, and nowhere is this as clearly visible as in medicine. "The edge of medicine" has become the title of books, scholarly articles, media headlines, and lecture series and seems to be imbued with hype, hope, and aversion. In order better to understand what is at stake at "the edge of medicine" this article addresses three questions: What does "the edge of medicine" mean in contemporary debates on modern medicine? What are the challenges "on the edge of medicine" (in these various meanings of "on the edge")? How can philosophy and ethics contribute with addressing these challenges?

METHODS

Literature searches in PubMed and Google Scholar are used to identify uses of the phrase "the edge of medicine" while conventional content analysis is used to analyze meanings of and challenges with "the edge of medicine." These results are then investigated with respect to how philosophy and ethics can address the identified challenges.

RESULTS

The literature reveals that "the edge of medicine" has many meanings, such as: Border; Margin (of life); Frontier; Forefront; Fringes; Plunge (abyss); Brink (verge); Conflict; and Balancing. In general, the various meanings address four basic challenges: setting limits, keeping control, make meaning, and handling conflicts or aporias. The analysis of each of the meanings of "the edge of medicine" identifies a wide range of important and urgent tasks for the humanities in general, and for philosophy and ethics in particular: 1) clarifying concepts; 2) clarifying assumptions and premises of arguments, methods, advice, and decisions; 3) elaborate new concepts and new theories; 4) conceptualize and handle uncertainty, moral regret, and residue; 5) reveal "the emperor's new clothes;" 6) identify trends and reflect on their implications; 7) demarcation; and 8) reflecting on goodness in medicine.

CONCLUSION

The phrase "the edge of medicine" expresses a wide range of challenges for modern health care. Together with other disciplines philosophy and ethics can and should make crucial contributions at "the edge of medicine," which is where the future of human beings and societies is created and formed.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

BACKGROUND

Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV).

METHODS

Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients.

RESULTS

The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians.

CONCLUSIONS

PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

Complex health care interventions: Characteristics relevant for ethical analysis in health technology assessment

Complexity entails methodological challenges in assessing health care interventions. In order to address these challenges, a series of characteristics of complexity have been identified in the Health Technology Assessment (HTA) literature. These characteristics are primarily identified and developed to facilitate effectiveness, safety, and cost-effectiveness analysis. However, ethics is also a constitutive part of HTA, and it is not given that the conceptions of complexity that appears relevant for effectiveness, safety, and cost-effectiveness analysis are also relevant and directly applicable for ethical analysis in HTA. The objective of this article is therefore to identify and elaborate a set of key characteristics of complex health care interventions relevant for addressing ethical aspects in HTA. We start by investigating the relevance of the characteristics of complex interventions, as defined in the HTA literature. Most aspects of complexity found to be important when assessing effectiveness, safety, and efficiency turn out also to be relevant when assessing ethical issues of a given health technology. However, the importance and relevance of the complexity characteristics may differ when addressing ethical issues rather than effectiveness. Moreover, the moral challenges of a health care intervention may themselves contribute to the complexity. After identifying and analysing existing conceptions of complexity, we synthesise a set of five key characteristics of complexity for addressing ethical aspects in HTA: 1) multiple and changing perspectives, 2) indeterminate phenomena, 3) uncertain causality, 4) unpredictable outcome, and 5) ethical complexity. This may serve as an analytic tool in addressing ethical issues in HTA of complex interventions.

Ethical analysis in HTA of complex health interventions

BACKGROUND

In the field of health technology assessment (HTA), there are several approaches that can be used for ethical analysis. However, there is a scarcity of literature that critically evaluates and compares the strength and weaknesses of these approaches when they are applied in practice. In this paper, we analyse the applicability of some selected approaches for addressing ethical issues in HTA in the field of complex health interventions. Complex health interventions have been the focus of methodological attention in HTA. However, the potential methodological challenges for ethical analysis are as yet unknown.

METHODS

Six of the most frequently described and applied ethical approaches in HTA were critically assessed against a set of five characteristics of complex health interventions: multiple and changing perspectives, indeterminate phenomena, uncertain causality, unpredictable outcomes, and ethical complexity. The assessments are based on literature and the authors' experiences of developing, applying and assessing the approaches.

RESULTS

The Interactive, participatory HTA approach is by its nature and flexibility, applicable across most complexity characteristics. Wide Reflective Equilibrium is also flexible and its openness to different perspectives makes it better suited for complex health interventions than more rigid conventional approaches, such as Principlism and Casuistry. Approaches developed for HTA purposes are fairly applicable for complex health interventions, which one could expect because they include various ethical perspectives, such as the HTA Core Model® and the Socratic approach.

CONCLUSION

This study shows how the applicability for addressing ethical issues in HTA of complex health interventions differs between the selected ethical approaches. Knowledge about these differences may be helpful when choosing and applying an approach for ethical analyses in HTA. We believe that the study contributes to increasing awareness and interest of the ethical aspects of complex health interventions in general.

A closer look at the role of healthcare in the recent mortality decline in the Netherlands: results of a record linkage study

BACKGROUND

Since 2002, Dutch mortality rates decreased rapidly after decades of stagnation. On the basis of indirect evidence, previous research has suggested that this decline was due to a sudden expansion of healthcare. We tested two corollaries of this hypothesis--first, that the decline was concentrated among those with ill-health and second, that the decline can be statistically accounted for by increases in healthcare utilisation.

METHODS

We linked the Dutch health interview survey to the mortality register and constructed two cohorts, consisting of 7691 persons interviewed in 2001/2002 and 8362 persons interviewed in 2007/2008, each with a 5-year mortality follow-up (659 deaths in total). The change in mortality between both cohorts was computed using Cox proportional hazard models. We estimated the change in mortality by severity of chronic conditions and with respect to the inclusion of indicators of healthcare utilisation.

RESULTS

Between the two study cohorts, mortality declined by 15% (95% CI 2% to 29%), and mortality reduction was greatest for those suffering from fatal and non-fatal conditions with a decline of 58% (95% CI 35% to 78%). Even after adjustment for health status and risk factors, most indicators of healthcare utilisation were associated with higher instead of lower mortality and changes in healthcare utilisation did not explain the decline in mortality.

CONCLUSIONS

Our results only partly confirm the hypothesis that an expansion of healthcare explains the recent mortality decline in the Netherlands. Owing to confounding by health status, it is difficult to reproduce the mortality-lowering effects of healthcare utilisation of individual level studies in the open population.

Modern health worries and visits to the general practitioner in a general population sample: an 18month follow-up study

OBJECTIVE

Modern health worries (MHW) are concerns about health risks from features of modern life (e.g. additives in food, contaminated water supply, drug resistant bacteria, etc.). We investigated the role of MHW for care seeking for all purposes at the general practitioner (GP) and studied the role of neuroticism, symptoms of anxiety and somatization, other health anxiety, self-rated health, age, education and gender on the association between MHW and care-seeking.

METHODS

A representative sample from eight GPs (n=5068) completed a baseline questionnaire on MHW, symptoms of health and personality, and was followed for visits to the GP for the next 18months in the registers from the GP.

RESULTS

Modern health worries were common, and higher levels were seen among women and in higher age. Care seeking at the GP was associated with MHW, and this association was maintained after adjusting for age, gender, neurotic traits, symptoms of anxiety, somatization, other health anxieties and self-rated health.

CONCLUSION

Over and beyond health related factors and personality, MHW had an independent role for future visits to the GP in the magnitude of 20% more visits among the participants in the highest quartile of the MHW-scale.

Mandatory reporting of elder abuse: between a rock and a hard place

PURPOSE

Despite mandated reporting laws that require physicians to report elder abuse, physicians have low rates of reporting. The purpose of this study was to identify physician's perspectives on mandated reporting of elder abuse.

METHODS

Individual, semistructured interviews were conducted with 20 primary care physicians practicing in a variety of settings and caring for a diverse patient population in the Los Angeles area. Interviewers collected information on physicians' perspectives about factors that may influence physicians' likelihood to report elder abuse. The interviews were recorded and transcribed verbatim. Transcripts were analyzed using a grounded theory approach based on the constant comparative method and the emergence of the core category of paradox to best account for the most problematic elder abuse situations faced by physicians.

RESULTS

During the interviews 3 paradoxes were expressed by physicians about the mandatory reporting of elder abuse. Specifically, mandatory reporting was related to both perceptions of increases and decreases in physician-patient rapport, patient quality of life, and physician control or ability to decide what is in the best interest of the patient. These paradoxes appear to be primarily hidden or unconscious, yet they influence the conscious decision process of whether to report.

CONCLUSIONS

Primary care physicians appear to be subject to paradoxes of reporting that contribute to the underreporting of elder abuse. These paradoxes and alternative modes of managing paradoxes are important and should be addressed in educational and training programs for physicians, and systematic evaluation of these issues may help to inform future legislation in this area. Further studies are needed to assess the generalizability of these findings to other groups of clinicians.