Counterattack: Miffed at Ontario Premier Dalton McGuinty’s efforts to organize a common provincial front to constrain the growth of physician fees, the nation’s medical associations have issued a missive assailing his government’s decision to discontinue contract negotiations and impose a new fee schedule. “The manner in which your government has imposed conditions on physicians without a true opportunity to build consensus is not acceptable and your efforts to convince the Premiers from the other provinces to adopt a broken model that excludes true collaboration are wrong-headed,” states the open letter from the presidents of the Canadian Medical Association and 11 provincial-territorial associations (www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2012/Letter-PremierOntario_en.pdf). “Imposing your views on physicians and the public is a leadership style that comes with great risk. Patients expect that governments will work with physicians and that, together, they will put patients’ interests first.” — Wayne Kondro, CMAJ
Pedagogic wonders: The province of Ontario should create “coaching teams” to teach workers at long-term care homes how to go about their business without abusing or neglecting residents, a task force of long-term care providers argues. The teams should be funded to “assist homes that are poor performers to improve resident quality and safety in their homes,” the Ontario Long Term Care Association, the Ontario Association of Non-Profit Homes and Services for Seniors, the Ontario Association of Residents’ Councils and Concerned Friends of Ontario Citizens in Care Facilities recommend in An Action Plan to Address Abuse and Neglect in Long-Term Care Homes (http://longtermcaretaskforce.ca/images/uploads/LTCFTReportEnglish.pdf). The recommendation was among 18 measures urged in hopes of reducing the roughly 3000 incidents of abuse in long-term care homes reported annually. Other recommendations included one that “strongly encouraged” homes to “regularly assess the competencies of staff.” — Wayne Kondro, CMAJ
Pass on PSA: The harms of regular prostate cancer screening outweigh the benefits, according to the United States Preventive Services Task Force. The prostate-specific antigen blood test, commonly called the PSA test, may prevent the death of 1 man in every 1000 who take it but another in every 3000 will die from complications from treatment, while dozens of others will be damaged, the task force indicates in a recommendation statement, Screening for Prostate Cancer (www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm). “There is convincing evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer. There is also convincing evidence that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man’s lifetime. The terms ‘overdiagnosis’ or ‘pseudo-disease’ are used to describe both situations. The rate of overdiagnosis of prostate cancer increases as the number of men subjected to biopsy increases. The number of cancer cases that could be detected in a screened population is large; a single study in which men eligible for PSA screening had biopsy regardless of PSA level detected cancer in nearly 25% of men. The rate of overdiagnosis also depends on life expectancy at the time of diagnosis. A cancer diagnosis in men with shorter life expectancies because of chronic diseases or age is much more likely to be overdiagnosis. The precise magnitude of overdiagnosis associated with any screening and treatment program is difficult to determine, but estimates from the 2 largest trials suggest overdiagnosis rates of 17% to 50% for prostate cancer screening.” — Wayne Kondro, CMAJ
Open your wallets: The annual average cost to provide health care for an American family of four has soared 6.9% to a record high of US$20 728, an increase of US$1335 over 2011, according to benefits consultant Millman. That includes out-of-pocket costs, such as copays and deductibles, of about US$3470 and US$5114 in payroll deductions, states the 2012 Millman Medical Index (http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf). The report indicates that the largest component of that $US20 728 tally was spent on physician services (US$6647), followed by inpatient hospital care (US$6531), outpatient care (US$3699); pharmacy (US$3056) and other (US$795). Millman also broke down costs by 14 major American cities and their analysis indicated that average annual costs varied substantially, with Miami topping the list ($US24 965), followed by New York City (US$24 545) and Chicago (US$23 551). Phoenix, Arizona, was the least expensive at US$18 365. — Wayne Kondro, CMAJ
Chronic redux: In the first salvo of its plan to craft the framework for a national food strategy, the Conference Board of Canada has unveiled a primer that sketches the role that an unhealthy diet plays as a risk factor for chronic disease, while urging commonly expressed views on the need to reduce salt and trans fat intakes, as well as improve food labelling requirements and children’s “food literacy.” Among other “potential solutions” are programs aimed squarely at high-risk subsets of the population, such as the obese, states the report, Improving Health Outcomes: The Role of Food in Addressing Chronic Diseases (www.conferenceboard.ca/e-library/abstract.aspx?did=4824). “By focusing on the highest-risk groups, initiatives to address dietary risks would have the greatest impact on reducing the proportion of the population that develops chronic diseases through food. To avoid public stigmatization, initiatives that support the efforts of primary physicians in dealing with their obese and seriously overweight patients provide a good starting point.” — Michael Monette, CMAJ
Theological tractate: The Franciscan University of Steubenville, Ohio, has discontinued its health care insurance plan for its employees and 2500 students rather than comply with the Patient Protection and Affordable Care Act, which compels coverage for “women’s health services,” such as contraception, sterilization and abortion-causing drugs. The university also announced that it and 42 other plaintiffs, representing a number of dioceses, educational institutions and charitable organizations have filed 12 lawsuits against United States President Barack Obama’s administration for introducing legislation that violates the “freedom to practice religion without government interference” (www.franciscan.edu/News/2012/Franciscan-Sues-For-Religious-Liberty/). “Franciscan University’s mission is and always has been to teach from the heart of the Church,” stated Father Terence Henry, the university’s president. “The Obama administration’s mandate is a grave threat to our ability to carry out that mission. It makes it impossible for us to operate freely as a Catholic institution without overbearing and invasive governmental interference.” In dropping its health care plan, Franciscan’s board of trustees stated that “we will not participate in a plan that requires us to violate the consistent teachings of the Catholic Church on the sacredness of human life.” — Wayne Kondro, CMAJ
Chan re-appointed: The World Health Assembly has appointed Dr. Margaret Chan to serve a second term at the helm of the World Health Organization. In her acceptance speech, Chan urged that WHO continue to press for expanded health coverage for disadvantaged peoples (www.who.int/dg/speeches/2012/wha_20120523/en/index.html ). “In my view, universal coverage is the single most powerful concept that public health has to offer. It is our ticket to greater efficiency and better quality. It is our saviour from the crushing weight of chronic noncommunicable diseases that now engulf the globe,” Chan stated. “Universal coverage is the umbrella concept that demands solutions to the biggest problems facing health systems. That is: rising health care costs yet poor access to essential medicines, especially affordable generic products; an emphasis on cure that leaves prevention by the wayside; costly private care for the privileged few, but second-rate care for everybody else; grossly inadequate numbers of staff, or the wrong mix of staff; weak or inappropriate information systems; weak regulatory control, and schemes for financing care that punish the poor. Universal coverage is the hallmark of a government’s commitment, its duty, to take care of its citizens, all of its citizens. Universal coverage is the ultimate expression of fairness.” Chan was elected director-general in 2006 and earned her medical degree from the University of Western Ontario before joining the Hong Kong Department of Health in 1978 and subsequently serving a nine-year stint as the country’s director of health. Her second term at the WHO helm runs from July 1 through June 30, 2017. — Wayne Kondro, CMAJ
Polio plan: Arguing that it desperately needs donations totalling US$1 billion to boost vaccination coverage in polio endemic countries, the Global Polio Eradication Initiative has launched an “emergency action plan” to ramp up its efforts in Nigeria, Pakistan and Afghanistan. “Polio eradication is at a tipping point between success and failure,” Dr. Margaret Chan, director general of the World Health Organization stated in a press release (www.polioeradication.org/tabid/461/iid/219/Default.aspx). “We are in emergency mode to tip it towards success — working faster and better, focusing on the areas where children are most vulnerable.” Eradication of polio in the three remaining countries in which the disease is endemic “is now a question of political and societal will,” added Kalyan Banerjee, president of Rotary International, a global humanitarian service organization. “Do we choose to deliver a polio-free world to future generations, or do we choose to allow 55 cases this year to turn into 200,000 children paralyzed for life, every single year?” Among the specific objectives of the emergency polio plan is one to “close the US$945 million funding gap for eradication activities in 2012–2013 and develop a long-term plan to ensure funding and political will for the Polio Eradication and Endgame Strategy 2014–2018” (www.polioeradication.org/Portals/0/Document/Resources/StrategyWork/EAP_201205.pdf). — Wayne Kondro, CMAJ
Paying parents for care: The New Zealand government’s refusal to allow parents to qualify for payments to provide home-based care to their disabled children is a violation of the country’s human rights law and various international conventions, the nation’s appellate court has ruled. It is discriminatory to preclude parents from eligibility for payments for such disabled support services as personal care (hygiene, dressing and feeding), household management (such as cleaning, laundry and meal preparation), “individualized funding” (a system of personalized budgets which allows a disabled person to self-manage support services), “contract” care (primarily for those with an intellectual disability, or support for “independent living,” which covers household, accommodation and other services provided to about 2000 New Zealanders, the Court of Appeal of New Zealand ruled in a case between the ministry of health and nine respondents (http://jdo.justice.govt.nz/jdo/GetJudgment/?judgmentID=210047). Nor is such prohibition a “justified limitation” of the New Zealand Bill of Rights Act (similar to the notwithstanding clause of the Canadian Charter of Rights and Freedoms), the court ruled in rejecting such ministry arguments that sought to prevent families from becoming reliant on the income, as well as avoid “professionalising or commercialising” family relationships. — Wayne Kondro, CMAJ
Routing prescriptions: American physicians are rapidly shifting to e-prescribing, according to the Surescripts health information network. There was a 75% increase in the number of prescriptions routed electronically in 2011 to 570 million, or 36% of prescriptions dispensed, from 326 million or 22% in 2010, Surescripts states in The national progress report on e-prescribing and interoperable health care year 2011 (www.surescripts.com/downloads/npr/National%20Progress%20Report%20on%20E%20Prescribing%20Year%202011.pdf). The report also indicates an analysis of 39 893 prescribers who began using e-prescribing in 2008 indicated that 60% meet the first test of United States regulations that made “meaningful use” of electronic health records a necessary condition to receive Medicare and Medicaid payments (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3361). As well, some 58% of office-based American physicians now e-prescribe and there is a “consistent 10 percent increase in patient first fill medication adherence (i.e., new prescriptions that were picked up by the patient) among physicians who adopted e-prescribing technology,” the report added, while noting that if the pace of e-prescribing benefits continued to increase, “between $140 billion and $240 billion in health care cost savings and improved health outcomes” could be achieved over the next decade. — Wayne Kondro, CMAJ
Deficient care: Only half of people with diabetes in England are receiving recommended care and about 24 000 are dying from conditions which could have been prevented, according to the United Kingdom’s National Audit Office. Despite the Department of Health having set “clear standards for good diabetes care, analysis from general practice records in the 2009–10 National Diabetes Audit found that under half (49 per cent) of people with diabetes received all the care processes recommended for the monitoring of risk factors for tissue damage. Without regular monitoring and treatment, this damage can lead to complications such as blindness, amputation and kidney disease, which significantly affect patients and NHS resources,” the audit office states in a report, The management of adult diabetes services in the NHS (www.nao.org.uk//idoc.ashx?docId=251214f2-7995-4882-a037-a95818535295&version=-1). “Less than one in five people with diabetes are achieving recommended treatment standards that reduce their risk of developing diabetes-related complications. The risk of developing complications can be minimised if people with diabetes achieve recommended treatment standards to control blood glucose, blood pressure, and cholesterol levels. Our analysis found that in 2009–10, 16 per cent of people with diabetes achieved all three treatment standards combined. Sixty-nine per cent of people with diabetes failed to achieve one or more of the three treatment standards and 15 per cent were not tested at all, putting both groups at a higher risk of developing future complications.” — Wayne Kondro, CMAJ
Prohibitive costs: The economic recession has resulted in a precipitous drop in the number of Americans who have employment-based health insurance, according to the Employee Benefit Research Institute. “Between December 2007, when the most recent economic recession officially started, and May 2008, the percentage of workers with coverage in their own names fell from 60.4 percent to 56.8 percent” and preliminary indications are that the level dropped further to 55.2% by June 2011, the Washington, DC–based institute stated in a report, Trends in Employment-Based Coverage Among Workers, and Access to Coverage Among Uninsured Workers, 1995–2011 (www.ebri.org/pdf/notespdf/EBRI_Notes_05_May-12.Hi-only.pdf). “Uninsured workers reported multiple reasons for not having coverage. Most workers reported that they did not have coverage because of cost,” the report added, noting that the number of workers citing cost as the reason for not having coverage reached 90% by June 2011. — Wayne Kondro, CMAJ
Better late than never: Over seven months after the United States made the move, federal Health Minister Leona Aglukkaq has indicated that the Canadian government plans to place methylenedioxypyrovalerone (MDPV) on schedule I of the Controlled Drugs and Substances Act. A stimulant that functions as a dopamine-norepinephrine reuptake inhibitor and a key component of the street drug known as “bath salts,” which can cause hallucinations, violent behaviour and tachycardia, MDPV will be declared illegal by this fall unless the government is convinced otherwise during public consultations (which are open through July 10). “This action helps give law enforcement the tools they need to keep our streets and communities safe from this new and emerging drug that ruins lives and causes havoc in communities across the country,” Aglukkaq stated in a press release (www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2012/2012-93-eng.php). — Wayne Kondro, CMAJ
Renal strategy: The Ontario Renal Network has unveiled a seven-step strategy to slow the progression of chronic kidney disease (CKD). Roughly 10 000 Ontarians now receive dialysis treatment for end-stage renal disease, at a cost of $586 million in fiscal 2012/13, the agency indicated (www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=134287). The Ontario Renal Plan 2012–2015 is built around seven priorities: “Strengthen accountability to patients; Reduce the impact of CKD by improving early detection and prevention of progression; Improve peritoneal and vascular access for dialysis patients; Improve uptake of independent dialysis; Ensure Ontario has the necessary infrastructure to care for CKD patients; Strengthen Ontario CKD care through research and innovation; [and] Align funding to high quality patient-focused care” (http://orp.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=131760). “The number of people living with chronic kidney disease risk factors in Ontario is rising,” Ontario Minister of Health and Long-Term Care Deb Matthews stated in a press release (www.renalnetwork.on.ca/common/pages/UserFile.aspx?fileId=134302). “This plan will work to keep Ontarians healthy by helping to slow the progression of CKD, while improving the quality of care and treatment for current and future patients.” — Wayne Kondro, CMAJ
Outback blues: Mental illness in men aged 12–25 takes an A$3.27-billion toll annually on the Australian economy, and costs A$387 000 per hour “across a year in lost productivity,” a report indicates. “The Federal Government bears 31% of this cost via direct health costs, disability welfare payments, unemployment benefits and the direct costs of imprisonment, states the report, Counting the Cost: The Impact of Young Men’s Mental Health on the Australian Economy, conducted by the nonprofit Inspire Foundation and health consultants Ernst & Young (www.cplx.com.au/Cost_of_Illness_Report.pdf). “Australia loses over 9 million working days per annum to young men with mental illness. On average they have an additional 9.5 days out of role per year. Young men with mental illness have much lower rates of educational attainment compared to their peers, further limiting their skills development and long term reduced earning potential by $559 million per year.” Minister for Mental Health and Ageing Mark Butler noted that “two thirds of mental illness emerges before the age of 21. If that illness is left untreated, it can impact on a person’s education, and later in life on their future career prospects and financial security. The clear message from Counting the Cost is that we must intervene early and invest smarter to reduce the cost and impacts associated with young men’s mental illness. We stand to gain from both a happier, healthier population and increased productivity” (www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr12-mb-mb042.htm). — Wayne Kondro, CMAJ