Medical Savings Accounts
Proposals for reforming medicare in Canada have included the adoption of Medical Savings Accounts (MSAs). Under such plans, governments would contribute funds into individuals' MSAs that could then be used to purchase health services. Unspent funds would accumulate and could eventually be spent on a broader range of goods and services. MSAs have the potential to give people greater control over access to health care services and incentives to seek the most competitively priced services. Samuel Shortt reviews the evidence about the effectiveness of these plans in several countries, including China and Singapore. In a related commentary David Gratzer argues in favour of implementing MSAs in Canada; in another commentary Jeremiah Hurley argues that MSAs are unlikely to advance the goals of controlling expenditures and making the health care system more equitable.
Problems with rapid HIV tests
Rapid, point-of-care HIV test kits promise a fast, sensitive screen for HIV antibodies. However, the British Columbia Centre for Disease Control (BCCDC) has identified problems with the sensitivity of these test kits. Since April 2002, when a Health Canada advisory was issued on the subject as a result of the BCCDC investigations, additional performance problems have been discovered and are reported in a fast-tracked letter to the editor from Michael Rekart and colleagues. In a related story, Patrick Sullivan interviews the director of an STD clinic in Toronto, who says that only 400 of 1900 people have returned for retesting after taking a rapid HIV test that produced false-negative results. In this issue's Health and Drug Alerts column Eric Wooltorton discusses rapid HIV tests and the steps physicians should take if patients have received negative test results in the past. [For public health reasons these articles were posted early on our Web site (www.cmaj.ca). — Ed.]
Updated breast cancer guidelines
Hugh Scarth and colleagues from Health Canada's Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer present a summary of the updated guidelines for choosing between mastectomy and lumpectomy for stage I and II breast cancer. The authors describe recent studies, which reinforce some of the committee's original 1998 recommendations and also address new recommendations related to topics such as the role of preoperative chemotherapy to allow for breast-conserving surgery. [The updated full-text report of guideline 3 and the new guide for patients are available at www .cmaj.ca. — Ed.]
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Adult kidney transplantation
Have outcomes improved over time for patients undergoing kidney transplantation? Douglas Schaubel and coauthors used data from a national population-based organ-failure registry to study the rates of death and graft failure among 11 482 Canadians with end-stage renal failure who received a kidney between 1981 and 1998. The authors looked at 4 periods (1981–85, 1986–89, 1990–94 and 1995–98) and found that, relative to the first period and after adjustment for age, sex, ethnic background, primary renal disease, follow-up time and source of donor organ, the mortality rate ratios dropped over time, from 0.70 (95% confidence interval [CI] 0.54–0.89) in 1986–89 to 0.65 (95% CI 0.52–0.82) in 1990–94 and to 0.53 (95% CI 0.41–0.67) in 1995–98. The rate ratios for graft failure also decreased over time, from 0.68 (95% CI 0.60–0.78) in 1986–89 to 0.62 (95% CI 0.54–0.70) in 1990–94 and to 0.51 (95% CI 0.44–0.58) in 1995–98; the decrease occurred mostly among recipients of cadaveric organs. The authors attribute the decline in mortality to refinements in patient care, and the decline in graft failures to improved immunotherapy and management of hyperlipidemia and hypertension.
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