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The Public Health Agency of Canada attributes the majority of active Tuberculosis (TB) cases in Canada to the reactivation of Latent Tuberculosis Infection (LTBI) post immigration. Since 70% of recent migrants to Canada originate from TB endemic regions of which PHAC anticipates 50% have LTBI, LTBI management and control is of growing importance in Canada. LTBI treatment is provided without cost to clients through Public Health Departments but treatment initiation and completion is suboptimal. The objective of the study was to identify the socio-economic characteristics, including those related to immigration, that are associated with LTBI treatment initiation and completion among the LTBI foreign-born population in Hamilton, Ontario, an important immigrant and refugee resettlement community. Method: A retrospective population cohort of all LTBI cases reported between January 2, 2009 to December 23, 2014. Multivariable probit and oprobit regression analysis was used and the results tested using sensitivity analyses. Results: Among 1,960 cases that are foreign-born, the LTBI treatment initiation rate was 22% and the unconditional completion rate 13%. LTBI medical screening at point of entry into Canada was strongly associated with initiation and completion of LTBI treatment (p<.01). Relative to young adults (aged 18-30 years), middle-aged adults (aged 31-49 years) were less likely to complete LTBI treatment (p<.05) and children (aged <18 years) were more likely to initiate treatment (p<.01) but not more likely to complete treatment. Having been born in a TB-endemic country and having immigrated within the past five years were not associated with treatment initiation or completion. Conclusion: The low rates of treatment initiation and completion in this population highlight a need for better strategies to improve use of LTBI treatment by foreign-born populations. Attempts to pursue such improvements through development of evidence-based policies for LTBI management are limited by incomplete reporting on key characteristics such as risk factors and demographic information. [ABSTRACT FROM AUTHOR]

Background: Long-standing concern exists over hospital use by people near or at the end of life (EOL) related to the appropriateness, quality, and cost of care in hospital. It is widely believed that most people die in hospital after an escalation in hospital use over the last year of life. As most deaths in high-income countries are not sudden or unexpected, opportunities exist for planning compassionate, effective, and evidence-based EOL care. Objective: Gain current population-based evidence for EOL health policy and services planning. Design: Retrospective study of population-based hospital utilization data. Setting/Subjects: All hospital patients in every Canadian province and territory except Quebec. All decedents with hospital separations in 2014-2015. Measures: Descriptive-comparative and logical regression analysis tests. Results: In 2014-2015, 3.5% of hospital episodes ended in death and 43.7% of all deaths in Canada (excluding Quebec) took place in hospital. 95.2% of those dying in hospital were only admitted once or twice during their last 365 days of life. 3.6% of those dying in hospital had been living in the community and receiving publicly funded home care before the hospital admission that ended in death, while 67.0% had been living at home without home care. 79.0% of hospital deaths followed an unplanned admission through the emergency room, with 70.5% arriving by ambulance. The hospital care provided in the last stay was largely noninterventionist. Conclusions: These findings reveal the need for a major reconceptualization of death, dying, and EOL care to ensure sufficient capacity of palliative home care and other services to support dying people and prevent the health and family caregiver crises that lead to hospital-based EOL care and death. [ABSTRACT FROM AUTHOR]

The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management of health care to reflect needs for care in populations and to integrate planning and management functions for health care expenditure, health care services and the health care workforce. We present a Health Care Sustainability Framework based on disaggregating the health care expenditure into separate planning components. Unlike other approaches to planning health care expenditure, this framework explicitly incorporates population health needs as a determinant of health care requirements, and provides a diagnostic tool for understanding the sources of expenditure increase. [ABSTRACT FROM PUBLISHER]

Motor vehicle accident (MVA) insurance in Canada is based primarily on two different compensation systems: (i) no-fault, in which policyholders are unable to seek recovery for losses caused by other parties (unless they have specified dollar or verbal thresholds) and (ii) tort, in which policyholders may seek general damages. As insurance companies pay for MVA-related health care costs, excess use of health care services may occur as a result of consumers' (accident victims) and/or producers' (health care providers) behavior - often referred to as the moral hazard of insurance. In the United States, moral hazard is greater for low dollar threshold no-fault insurance compared with tort systems. In Canada, high dollar threshold or pure no-fault versus tort systems are associated with faster patient recovery and reduced MVA claims. These findings suggest that high threshold no-fault or pure no-fault compensation systems may be associated with improved outcomes for patients and reduced moral hazard. [ABSTRACT FROM AUTHOR]

Traditional approaches to health human resources planning emphasize the effects of demographic change on the needs for health human resources. Planning requirements are largely based on the size and demographic mix of the population applied to simple population-provider or population-utilization ratios. We develop an extended analytical framework based on the production of health-care services and the multiple determinants of health human resource requirements. The requirements for human resources are shown to depend on four separate elements: demography, epidemiology, standards of care, and provider productivity. The application of the framework is illustrated using hypothetical scenarios for the population of the combined provinces of Atlantic Canada. [ABSTRACT FROM AUTHOR]

Objectives: Using an administrative database of dental service records from the Non-Insured Health Benefits (NIHB) program of Health Canada for 1994-2001, the authors set out to test whether regular visitors had lower program expenditures.Methods: The age-specific mean expenditures per client were compared among those with regular examinations in 8, 7 and fewer years. The study further examined the effect of regular visiting over the first 6 years on expenditures in the last 2 years. "Continuity of care" was measured by the numbers of consecutive years prior to 2000 in which clients had a regular examination. In a "gap analysis" individuals were classified according to the number of years prior to 2000 since they last had an initial or recall examination. Mean expenditures per client were analyzed by age group and type of service.Findings: Over the 8-year period, clients with regular visits had the highest expenditures. In both the continuity of care and gap analyses, the findings were generally consistent; the more that clients visited over the first 6 years, the higher the expenditures in the final 2 years. Clients with more "regular" (initial and recall) examinations received a relatively standard, age-specific, pattern of service but incurred greater expenditures compared to clients with fewer regular, or longer gaps in, examinations.Conclusion: The observations of the authors in this client group do not support the thesis that regular visiting is associated with lower expenditures on dental care. [ABSTRACT FROM AUTHOR]

Health care policy in Canada is based on providing public funding for medically necessary physician and hospital-based services free at the point of delivery ("first-dollar public funding"). Studies consistently show that the introduction of public funding to support the provision of health care services free at the point of delivery is associated with increases in the proportionate share of services used by the poor and in population distributions of services that are independent of income. Claims about the success of Canada's health care policy tend to be based on these findings, without reference to medical necessity. This article adopts a needs-based perspective to reviewing the distribution of health care services. Despite the removal of user prices, significant barriers remain to services being distributed in accordance with need--the objective of needs-based access to services remains elusive. The increased fiscal pressures imposed on health care in the 1990s, together with the failure of health care policy to encompass the changing nature of health care delivery, seem to represent further departures from policy objectives. In addition, there is evidence of increasing public dissatisfaction with the performance of the system. A return to modest increases in public funding in the new millennium has not been sufficient to arrest these trends. Widespread support for first-dollar public funding needs to be accompanied by greater attention to the scope of the legislation and the adoption of a needs-based focus among health care policymakers. [ABSTRACT FROM AUTHOR]

Analysis of mammography utilization has traditionally been performed from an individual-level perspective. The purpose of this study was to explore the combined influence of individual- and regional-level determinants of mammography utilization. Logistic hierarchical multilevel modelling was used to investigate the influences of region of residence and individual characteristics on mammography utilization. Socio-economic status information about health planning regions was derived from the 1996 Canadian Census. Individual-level information was extracted from the 1996 National Population Health Survey. After controlling for individual-level education, regions with fewer high school graduates had lower levels of mammography utilization. A cross-level interaction between regional-level education and individual-level social involvement was found. Other individual-level variables associated with screening confirmed previous literature findings. Our findings suggest that higher levels of participation in social activities modify the detrimental influence on mammography utilization of living in a less educated region. This challenges the current focus of mammography screening research on individual-level determinants of uptake. Multilevel, synergistic strategies to possibly achieve higher levels of screening should be considered by health promotion program planners. [ABSTRACT FROM AUTHOR]

Presents an overview and preliminary empirical assessment of the social and economic determinants of health in Hamilton, Ontario, Canada. Search for ways of identifying the similarities and differences in the spatial patterning of places; Potential of spatial statistics and geographic information systems to address shortcomings in approaches used to characterize neighborhoods; Use of component analysis to reduce data and extract components that represent underlying local processes.

Explores issues on health-care resource allocation for a Canadian native population, that of Sioux Lookout Zone, within the context of the total provincial population. Rationale for a needs-based approach; Developing a needs-based approach; Native health conditions; Definition of the `fair share' concept; Results and discussion.

Validates a self-administered postal questionnaire appraising risk of coronary heart disease in Canada. Background information on the screening of hypercholesterolaemia; Subjects and methods used in the study; Findings and discussion. INSET: Toronto Working Group's criteria for cholesterol measurement.

In recent years considerable attention has been given to the effects of universal, first-dollar coverage for health care services as provided under Canada's health care system. However, no consideration has been given to the stability of these effects through periods of changing economic climate. In this paper we consider the extent to which the achievements of the Canadian approach to health care funding have been maintained in the presence of increasing attention to cost containment. Multivariate analyses are used to (a) explain variations in utilization of family physician services among the population and (b) explore the relationship between utilization and need for periods of differing economic circumstances. We observe that the relative importance of differences in need in explaining variations in use among the population was less in the period when cost containment was of greater concern. These findings indicate that policymakers cannot assume that removing financial barriers to access to service, although important in achieving a more equitable distribution of service utilization, may be sufficient to sustain such distributions during time of constraint. [ABSTRACT FROM AUTHOR]

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Examines the inclusion of drugs in provincial drug benefit programs. Use of the cost-effectiveness approach by the Ontario Drug Quality and Therapeutics Committee (DQTC) and how it has lead to continuous and considerable increases in expenditures; Way in which the economics approach to health improvements differs from the way in which the DQTC uses information on the costs and effects of pharmaceuticals; How economics can help.

In the article, the authors discuss the importance of improved data collection and management in the effective care of people with latent tuberculosis (TB) infection in Canada. Topics include the issues in effective data collection like the lack of regulation mandating latent TB infection screening in the immigration medical screening program, the cases of latent TB infection among immigrants, and the need to maintain records in the Integrated Public Health Information System (iPHIS).

An introduction to the issue and its special theme of human resources in the health care industry of Canada is presented, with reference to articles on manpower planning, health care provider productivity, job satisfaction among nurses, and other topics.

Comments on the system of charging patients for health care in Canada. Way to raise any particular revenue target from patient charges; Suggestions to determine eligibility for health-user tax exemption status; Importance of considering the nature of any inappropriate use of health care.

The article points out some of the lessons that can be learned by Canadian policy makers on the financial support and delivery of oral health care provided by Australia, Great Britain, New Zealand, and the U.S. According to the authors, government expenditures per capita on oral health care in Canada are high compared with the four countries. They add that countries in North America support publicly funded oral health programs for children.

Background: An increasing number of countries are introducing new health professions, such as Nurse Practitioners (NPs) and Physician Assistants (PAs). There is however limited evidence, on whether these new professions are included in countries' workforce planning., Methods: A cross-country comparison of workforce planning methods. Countries with NPs and/or PAs were identified, workforce planning projections reviewed and differences in outcomes were analysed, based on a review of workforce planning models and a scoping review. Data on multi-professional (physicians/NPs/PAs) vs. physician-only models were extracted and compared descriptively. Analysis of policy implications was based on policy documents and grey literature., Results: Of eight countries with NPs/PAs, three (Canada, the Netherlands, United States) included these professions in their workforce planning. In Canada, NPs were partially included in Ontario's needs-based projection, yet only as one parameter to enhance efficiency. In the United States and the Netherlands, NPs/PAs were covered as one of several scenarios. Compared with physician-only models, multi-professional models resulted in lower physician manpower projections, primarily in primary care. A weakness of the multi-professional models was the accuracy of data on substitution. Impacts on policy were limited, except for the Netherlands., Conclusions: Few countries have integrated NPs/PAs into workforce planning. Yet, those with multi-professional models reveal considerable differences in projected workforce outcomes. Countries should develop several scenarios with and without NPs/PAs to inform policy., (Copyright © 2018. Published by Elsevier B.V.)

Competing Interests: Competing interests: None declared.

Celiac disease affects 1% of the North American population, with an estimated 350,000 Canadians diagnosed with this condition. The disease is triggered by the ingestion of gluten, and a lifelong, strict gluten-free diet (GFD) is the only currently available treatment. Compliance with a strict GFD is essential not only for intestinal mucosal recovery and alleviation of symptoms, but also for the prevention of complications such as anemia, osteoporotic fractures and small bowel lymphoma. However, a GFD is difficult to follow, socially inconvenient and expensive. Different approaches, such as tax reduction, cash transfer, food provision, prescription and subsidy, have been used to reduce the additional costs of the GFD to patients with celiac disease. The current review showed that the systems in place exhibit particular advantages and disadvantages in relation to promoting uptake and compliance with GFD. The tax offset system used in Canada for GFD coverage takes the form of a reimbursement of a cost previously incurred. Hence, the program does not help celiac patients meet the incremental cost of the GFD - it simply provides some future refund of that cost. An ideal balanced approach would involve subsidizing gluten-free products through controlled vouchers or direct food provision to those who most need it, independently of 'ability or willingness to pay'. Moreover, if the cost of such a program is inhibitive, the value of the benefits could be made taxable to ensure that any patient contribution, in terms of additional taxation, is directly related to ability to pay. The limited coverage of GFD in Canada is concerning. There is an unmet need for GFD among celiac patients in Canada. More efforts are required by the Canadian medical community and the Canadian Celiac Association to act as agents in identifying ways of improving resource allocation in celiac disease.

Objective: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada., Methods: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the 'gap' between these were simulated., Results: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage., Conclusions: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Health human resource planning has traditionally been based on simple models of demographic changes applied to observed levels of service utilization or provider supply. No consideration has been given to the implications of changing levels of need within populations over time. Recently, needs based resource planning models have been suggested that incorporate changes in needs for care explicitly as a determinant of health care needs., Methods: In this paper, population indicators of morbidity, mortality and self-assessed health are analyzed to determine if health care needs have changed across birth cohorts in Canada from 1994 to 2005 among older age groups. Multivariate regression analysis was used to estimate the age pattern of health by birth year with interaction terms included to examine whether the association of age with health was conditional on the birth year., Results: Results indicate that while the probability of mortality, mobility problems and pain rises with age, the rate of change is greater for those born earlier. The probability of self-assessed poor health increases with age but the rate of change with age is constant across birth years., Conclusions: Even in the short time period covered, our analysis shows that health care needs by age are changing over time in Canada.

The vast majority of the 220,000 Canadians who die each year, principally of old age and progressive ill health, do not have access to specialized hospice or palliative care. Hospice and palliative care programs are unevenly distributed across Canada, with existing programs limited in capacity and services varying considerably across programs. End-of-life (EOL) care is defined as "The services that may be needed by dying persons and their families or friends in the last year of life, as well as bereavement services following death." Although some health and social services may be available, most dying Canadians are in the difficult position of not having ready access to a full range of services that could ease their final days of life. Most are thus at risk of uncoordinated and potentially inadequate EOL care. Among all persons, dying persons are arguably the most vulnerable. The dying process is often difficult as a result of emotional and physical challenges. Although the loving support of family and friends for dying persons is irreplaceable, EOL care is an important public obligation. A synthesis research project was conducted to identify a best-practice EOL care model for Canada, one featuring coordinated or integrated EOL care. Through site visits, literature reviews, Web-based surveys, and a home care data analysis, four essential components for a best-practice integrated EOL care model for Canada were identified: (a) universality, (b) care coordination, (c) assured access to a broad range of basic and advanced EOL services, and (d) EOL care provision regardless of care setting. This model is offered as a guide for the development of EOL care services across Canada.

Background: Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost-effectiveness., Methods: A state-transition Markov model for a hypothetical cohort of women age 50 years was used to evaluate the effects of tamoxifen on mortality and tamoxifen price on cost-effectiveness. Incidence and mortality rates for breast and endometrial cancers were derived from Surveillance, Epidemiology and End Results statistics, and noncancer outcomes were obtained from published studies. Relative risks of outcomes were derived from the National Surgical Adjuvant Breast and Bowel Project P-1 trial. Costs were based on Medicare reimbursements., Results: Projected overall mortality for women at 1.67% 5-year breast cancer risk showed little difference with or without tamoxifen, resulting in a cost-effectiveness ratio of $1,335,690 per life-year saved as a result of tamoxifen use. Adjusting for the differential impact of estrogen receptor-negative cancers, tamoxifen increased mortality for women with a uterus until the 5-year breast cancer risk reached > or =2.1%. Assigning the Canadian price for tamoxifen dramatically reduced the incremental cost (to $123,780 per life-year saved). At that price, the use of tamoxifen was less costly and more effective for women with 5-year breast cancer risks >4%., Conclusions: Tamoxifen may increase mortality in women at the lower end of the "high-risk" range for breast cancer. If prices in the U.S. approximated Canadian prices, then tamoxifen use for breast cancer risk reduction in women with a 5-year risk >3% could be a reasonable strategy to reduce the incidence of breast cancer. Because they are used by many unaffected individuals, the price of chemopreventive agents has a major influence on their cost-effectiveness.

It has been suggested that scepticism among decision-makers about using cost-effectiveness analysis (CEA) is caused in part by the low level of the cost-effectiveness "thresholds" in the economic evaluation literature. This has led Ubel and colleagues to call for higher threshold values of US$200,000 or more per quality-adjusted life-year. We show that these arguments fail to identify the objective of CEA and hence do not consider whether or how the threshold relates to this objective. We show that incremental cost-effectiveness ratios (ICERs) cannot be used to identify an efficient use of resources--the "biggest bang for the bucks"--allocated to health care. On the contrary, the practical consequence of using the ICER approach is shown to be an increase in health care expenditures, or "bigger bucks for making a bang", without any evidence of the bang being bigger (i.e. that this leads to an increase in benefits to the population). We present an alternative approach that provides an unambiguous method of determining whether a new intervention leads to an increase in health gains from whatever resources are to be made available to health care decision-makers.

Background: There has been an increased focus on home care service provision in recent years, yet there are few data available about the provision of home and community occupational therapy for children and youth., Purpose: To evaluate key elements of a service provision model for home care occupational therapy in terms of occupational performance outcomes, perception of care and cost., Methods: Eleven centres in Ontario and Quebec recruited 167 children and youth up to 18 years of age to a before and after study of occupational therapy services in the home and community. Occupational performance, quality of life and costs were measured at baseline and study end. Perception of care was measured at study completion., Results: A statistically and clinically significant improvement in occupational performance was demonstrated (p < 0.001). The clients' families gave high ratings to the process of care provided by the occupational therapists. These data did not demonstrate a clear relationship between amount of service, cost and occupational performance outcome., Practice Implications: Children receiving home and community occupational therapy services change in their occupational performance abilities. These changes are not directly related to the amount or focus of the occupational therapy services.

This article examines the degree to which relationships between social capital and health are embedded in local geographical contexts and influenced by demographic factors, socio-economic status, health behaviours and coping skills. Using data from a telephone survey of a random sample of adults (N=1504 respondents, response rate=60%), the article determines if relationships between involvement in voluntary associations and various measures of individual health are associated with neighbourhood of residence in the mid-sized city of Hamilton, Canada. Associational involvement and overweight status (assessed by body-mass score) were weakly but significantly related after controlling for the other variables; involvement had relationships with self-rated health and emotional distress before but not after controlling for socio-economic status, health behaviours and coping skills. Relationships between neighbourhood of residence and two health outcomes, self-rated health and overweight status, were statistically significant before and after controlling for the other characteristics of respondents; neighbourhood of residence was not a significant predictor of number of chronic conditions and emotional distress in multivariate models. The neighbourhood and associational involvement relationships with health were not dependent upon one another, suggesting that neighbourhood of residence did not help to explain the positive health effects of this particular measure of social capital.

Objective: We describe service patterns and compare changes in program expenditures with the Consumer Price Index over eight years in a dental program with a controlled-fee schedule offered to Canadian First Nations and Inuit people., Methods: We obtained the computerized records of dental services for the period from 1994 to 2001. Each record identified the date and type of service, region and type of provider, age of the client and encrypted identifying information on clients, bands, and providers. We classified the individual services into related types (diagnostic, preventive, etc.). We aggregated the records by client and developed indices for the numbers of clients, mean numbers of services per client, cost per service, and prices., Findings: Over the 8 years, 16.0 million procedures, totaling 811.8 million dollars, were provided to 538,034 different individuals, approximately 76% of the eligible population. Restorative procedures accounted for 36% of all expenditures followed by diagnostic (12.7%), preventive (12.2%), and orthodontic (8.9%) services. For much of the period, increases in program expenditures were exceeded by increases in the Consumer Price Index. This was consistent with fewer services per client, a less expensive mix of services, and relatively flat prices. However, in 2000 and 2001 higher prices and more clients resulted in increasing expenditures., Conclusions: Program expenditures were influenced by different factors over the study period. In the final two years, increasing expenditures were driven by price increases and increasing numbers of clients, but not by increasing numbers of services per client, nor a 'richer' mix of services.

The objective of this study was to assess if interaction between users and producers of research is associated with a greater level of adoption of research findings in the design and delivery of health care programs. Responses to the dissemination of a research report on breast cancer prevention were compared between two groups of public health units in Ontario, Canada. Although all public health units received the report, only a subset of units was involved in the development of the report, while others were not. Research utilisation was conceptualized in terms of stages, including reading the report, information processing, and application of findings for public health units' policies and programs. Using a multi-case study design, three units that contributed to the report's production (the interacting units) were compared with three units were not involved in producing the report (the comparison units) on the basis of research utilisation. Data collection involved group interviews and document review. Results demonstrated that interacting units had a greater understanding of the report's analysis and attached greater value to the report. However, interaction was not associated with greater levels of utilisation in terms of application. Both interacting and comparison units used the research findings to confirm that their on-going program activities were consistent with the research findings, and to compare their program performance relative to other units. In conclusion, interaction influenced the understanding of the research, and intent to use the research findings, but applied use was independent of interaction between producers and users of research.

There is almost universal agreement that the quality of clinical trials of acupuncture is poor. There is an urgent need to improve their quality. The author develops here a list of 45 criteria important in the design, implementation, and writing up of controlled clinical acupuncture trials. This list has been compiled after examining the quality assessment criteria used in meta-analyses and systematic reviews of acupuncture, general publications on clinical trial designs and methodological considerations specific to acupuncture trials. Each criterion is discussed with recommendations about use and implementation. Additionally, each criterion is discussed relative to their importance in three types of acupuncture trial, acupuncture versus sham acupuncture, acupuncture versus standard therapy and acupuncture versus no treatment or wait-list. It is hoped that this exploration and systematic presentation of the 45 criteria will contribute to improving the quality of clinical trials of acupuncture. Improved trial quality will lead to greater ease interpreting the results of trials, especially in systematic reviews., (Copyright Mary Ann Liebert, Inc.)

Unlabelled: OVERVIEW AND METHODS: This paper discusses those medical conditions in which clinical trials of acupuncture have been conducted, and where meta-analyses or systematic reviews have been published. It focuses on the general conclusions of these reviews by further examining official reviews conducted in the United States, United Kingdom, Europe, and Canada each of which examined available systematic reviews. While all reviews agree that the methodological rigor of acupuncture clinical trials has generally been poor and that higher quality clinical trials are necessary, this has not completely hampered the interpretation of the results of these clinical trials. In some conditions the evidence of efficacy has clearly reached a sufficient critical mass from enough well-designed studies to draw clear conclusions; for the rest, the evidence is difficult to clearly interpret. This paper also examines conclusions from the same international reviews on the safety and adverse effects of acupuncture. Here, conclusions are more easily drawn and there is good agreement about the safety of acupuncture., Results and Conclusions: General international agreement has emerged that acupuncture appears to be effective for postoperative dental pain, postoperative nausea and vomiting, and chemotherapy-related nausea and vomiting. For migraine, low-back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. For smoking cessation, tinnitus, and weight loss the evidence is usually regarded as negative. Reviews have concluded that while not free from serious adverse events, they are rare and that acupuncture is a relatively safe procedure., (Copyright Mary Ann Liebert, Inc.)

The National Institute for Clinical Excellence has published guidelines for economic evaluations for considering whether new health care technologies contribute to the efficient use of National Health Service resources. The analytical basis of the guidelines is a comparison of the costs and consequences of new and existing methods for dealing with particular conditions using the incremental cost-effectiveness ratio (ICER). However, this fails to provide an explicit and systematic basis for addressing the dual objectives of health maximisation and equitable availability of technologies in the context of a fixed NHS budget. We show that information on the costs and consequences of a particular technology is insufficient to address issues of efficiency of resource use. In addition, information is required about the total resources available and the alternative uses of those resources. Moreover, because these factors are unlikely to be identical for all settings, it is unlikely that the efficiency of using resources to support a new technology will be the same for all settings, even if the cost and consequences of the technology are the same across settings. Instead of improving the health outcomes from NHS resources, we show that using NICE guidelines to inform decisions about new technologies may lead to increased resources allocated to new technology, increased local variations in the use of new technologies and concerns about the sustainability and affordability of public funding for new technologies.

While there is a large and growing literature investigating the relationship between an individual's employment status and health, considerably less is known about the effect on this relationship of the context in which unemployment occurs. The aim of this paper is test for the presence and nature of contextual effects in the ways unemployment and health are related, based on a simple underlying model of stress, social support and health using a large population health survey. An individual's health can be influenced directly by own exposure to unemployment and by exposure to unemployment in the individual's context, and indirectly by the effects these exposures have on the relationship between other health determinants and health. Based on this conceptualization an empirical model, using multi-level analysis, is formulated that identifies a five-stage process for exploring these complex pathways through which unemployment affects health. Results showed that the association of individual unemployment with perceived health is statistically significant. Nevertheless, this study did not provide evidence to support the hypothesis that the association of unemployment with health status depends upon whether the experience of unemployment is shared with people living in the same environment. Above all, this study demonstrates both the subtlety and complexity of individual- and contextual-level influences on the health of individuals. Our results caution against simplistic interpretations of the unemployment-health relationship and reinforce the importance of using multi-level statistical methods for investigation of it.