Real Effective Corporate Tax Rates in Canada and the United States. After Tax Reform

Both Canada and the United States have recently undertaken comprehensive reforms of their tax systems. In the case of the corporate tax, the main thrust of the reforms has been to lower tax rates,broaden the tax base, and curtail or eliminate incentives such as investment tax credits. This article examines the significance for Canada of the corporate tax reforms in both countries. It uses the concept of the marginal real effectivetax rate on new investment to analyze the impact of the corporatetax changes on the size and distribution of the corporate tax burdenin each country, given various assumptions about the rate of inflation and the extent to which investment is debt financed. It is in the manufacturing sector that competition between Canada andthe United States is most intense and that real effective corporate tax rates probably have their greatest potential impact on the location of investment and employment. Before tax reform, the real effective tax rateon manufacturing investment in machinery and equipment in Canada was considerably lower than the rate in the United States. Under the post-reform regime, however, Canada's advantage is significantly smaller and decreases as the degree of debt financing increases.Indeed, in the absence of the investment incentives introduced by Ontario and Quebec in 1988, Canada's favourable tax position in the critical area of manufacturing investment in machinery andequipment would be lost altogether. In contrast, tax reform has significantly increased the real effective taxrate on equity-financed investment in non-residential construction in the United States, but not the rate in Canada. In this case, tax reform has transformed what was a tax advantage for the United States into an advantage for Canada. The overall effect of tax reform in the two countries, given the real effective tax rates, appropriately weighted, for both investment in machinery and equipment and investment in non-residential construction, has been to slightly reduce Canada's tax advantage in the manufacturing sector. This advantage is still a substantial one, however. Two important questions emerge from the analysis. First, what are the implications of the factthat federal efforts to reduce tax incentives for manufacturing investment in machinery and equipment have been offset by subsequent provincial efforts to restore the preferential position of their manufacturing sectors? Second, given that one of the main rationales for the Canadian tax reform package was that it would reduce tax-induced distortion of resource allocation by reducing or eliminating special tax incentives, why has reform actually increased the relative value of the tax credit for investment in the Atlantic region

Hospital service use in the last year of life by Indigenous Australians who died of heart failure or cardiomyopathy : a linked data study

Background: Aboriginal and Torres Strait Islander peoples experience disproportionate rates of heart failure. However, information regarding their use of hospital services in the last year of life is poorly delineated to inform culturally appropriate end-of-life health services. Objectives: To quantify hospital service use in the last year of life of Aboriginal and Torres Strait Islander peoples who died of heart failure or cardiomyopathy in Queensland, Australia. Methods: A subgroup analysis of a larger retrospective linkage study using administrative health data in Queensland, Australia. Individuals that identified as an Aboriginal and Torres Strait Islander person from their first hospital admission in the last year of life, who died of heart failure or cardiomyopathy from 2008 to 2018, were included. Results: There were 99 individuals, with emergency department presentation/s recorded for 85 individuals. Over 50% of individuals presenting to the Emergency Department were from regional areas (n = 43, 51%). The 99 individuals had a total of 472 hospital admissions, excluding same day admissions for haemodialysis, and 70% (n = 70) died in hospital. Most admissions were coded as acute care (n = 442, 94%), and fewer were coded as palliative care (n = 19, 4%). Median comorbidities or factors that led to hospital contact = 5 (interquartile range 3–9). Conclusion: Acute care hospital admissions in the last year of life by this population are common for those who died of heart failure or cardiomyopathy. Multimorbidity is prevalent in the last year of life, underscoring the importance of primary health care, provided by nurses and Indigenous health workers

The role of illness perceptions in delayed care-seeking in heart failure: A mixed-methods study

Background: Unclear illness perceptions are common in heart failure. The self-regulation model of illness behaviour highlights factors that may impact how people with chronic illness choose to cope with or manage their condition and has been used to study pre-hospital delay for stroke and acute myocardial infarction. The principles of self-regulation can be applied in heart failure to help illuminate the link between unclear illness perceptions and sub-optimal symptom self-management. Objective: Informed by the self-regulation model of illness behaviour, this study examines the role of illness perceptions in coping responses that lead to delayed care-seeking for heart failure symptoms. Design: Mixed-methods phenomenological study. Setting(s): Quaternary referral hospital - centre of excellence for cardiovascular care and heart transplantation. Participants: Seventy-two symptomatic patients with heart failure participated in a survey assessing illness perceptions. A subset of fifteen individuals was invited to participate in semi-structured interviews. Methods: Illness perceptions were assessed using the Brief Illness Perception Questionnaire. In-depth semi-structured interviews were conducted to elicit previous care-seeking experiences and decision-making that led to a passive, or active coping response to worsening symptoms. Descriptive statistics were used to report questionnaire findings, and open-ended responses were grouped into descriptive categories. Interpretative phenomenological analysis was undertaken on interview transcripts. Results: Participants perceived little personal control over their condition and mostly attributed heart failure to lifestyle factors such as diet and lack of activity. Cognitive dissonance between perceived self-identity and heart failure-identity led to a highly emotional response which drove coping towards avoidance strategies and denial. Conclusions: This study demonstrates the use of the principles of self-regulation in heart failure and offers a framework to understand how patient representations and emotional responses can inform behaviour in illness. Findings highlight the value of empowering patients to take control of their health and the need to help align values (e.g. independence) with behaviours (e.g. actively addressing problems) to facilitate optimal symptom self-management

The Patient Experience After Spontaneous Coronary Artery Dissection

Objective: There is considerable burden of anxiety, depression, and post-traumatic stress disorder in patients with spontaneous coronary artery dissection (SCAD), yet research is limited on the experience and impact of SCAD from the patient perspective. This literature review sought to describe the current state of the literature on the patient experience of SCAD and consequences for patients following a SCAD event from the patient perspective. To better understand how people\u27s experiences of SCAD affect their wellbeing, quality of life, lifestyles, and identity, and what would be useful from the patient perspective, an integrative review was performed. Methods: An integrative literature review was conducted to understand the experience of SCAD and the post-event implications. Five databases were searched. Search terms included ‘spontaneous coronary artery dissection’, ‘SCAD’, ‘patient’, ‘experience’, ‘perspective’, and ‘opinion’. English-language, peer-reviewed primary research in people with a diagnosis of SCAD that reflected the patient experience was included. Data indicating the SCAD experience including distress prevalence were extracted into an Excel spreadsheet, and narrative synthesis of included studies followed. Findings: From 325 identified studies, five were included for review, yielding a combined sample of 447 participants. Patients with SCAD reported a lack of information about SCAD and the recovery process, and use of the internet for obtaining information. Patients with SCAD reported challenges in recovery including anxiety associated with fear of recurrence and uncertainty, and a need for greater support. A wide range of negative emotions was reported during and after the SCAD event. Participants reported participating in support groups, with mixed reviews of their appropriateness and effectiveness

Elements of Integrated Palliative Care in Chronic Heart Failure Across the Care Continuum: A Scoping Review

Background: Individuals with chronic heart failure experience high symptom burden, reduced quality of life and high health care utilisation. Although there is growing evidence that a palliative approach, provided concurrently with usual treatment improves outcomes, the method of integrating palliative care for individuals living with chronic heart failure across the care continuum remains elusive.Aim: To examine the key elements of integrated palliative care recommended for individuals living with chronic heart failure across the care continuum.Design: Scoping review.Data sources: Databases searched were CINAHL, Ovid MEDLINE, Scopus and OpenGrey. Studies written in English and containing key strategic elements specific to chronic heart failure were included. Search terms relating to palliative care and chronic heart failure and the Joanna Briggs Institute methodology for scoping reviews was used.Results: Seventy-nine (79) articles were selected that described key elements to integrate palliative care for individuals with chronic heart failure. This review identifies four levels of key strategic elements: 1) clinical; 2) professional; 3) organisational and 4) system-level integration. Implementing strategies across these elements facilitates integrated palliative care for individuals with chronic heart failure.Conclusions: Inter-sectorial collaborations across systems and the intersection of health and social services are essential to delivering integrated, person-centred palliative care. Further research focussing on patient and family needs at a system-level is needed. Research with strong theoretical underpinnings utilising implementation science methods are required to achieve and sustain complex behaviour change to translate key elements

Heart failure deaths in Queensland: Hospital use in the last year of life

Background: Individuals with heart failure experience high symptom burden and poor quality of life with hospitalisations occurring right up until death. Understanding hospital-based service use by individuals with heart failure is crucial to inform health service development including palliative care services which may address patient needs and reduce hospital service use. Aims: To examine hospital-based service use in the last year of life by individuals aged ≥40 years old who died of heart failure in Queensland from 1 July 2008 to 31 December 2018. Methods: Linked Queensland Health administrative data containing information on hospitalisations, emergency department visits and death data were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Australian Modification (ICD-10-AM) diagnostic codes. Preliminary data analyses utilised descriptive statistics.Results: During the ten-year period, there were 6125 deaths with an underlying cause of death of heart failure, of which, 51% were female (n=3140). There were 27,780 admissions to hospital during this time, the majority were aged ≥ 80 years (n=15693, 56.4%), and were mostly treated in an acute ward (n=24818, 89%), while few (n=881, 3.2%) were in a palliative care ward. There were 11,776 emergency department visits, of which, 44.6% (n=5252) were by females and most visits (n=7860, 67%) resulted in an admission. The average cost of an admitted emergency department visit in Queensland from 2010 to 2018 was $945, equating to over$7 million dollars over the 8 year period.Conclusion: Many individuals with heart failure seek care in a hospital setting during the last year of life, with the majority being treated in an acute ward. Further analysis of the data will be conducted to determine the characteristics associated with higher hospital-based service use in the last year of life and if palliative care influenced hospital service use

Palliative care in chronic heart failure: a theoretically guided, qualitative meta-synthesis of decision-making

International clinical practice guidelines recommend that patients with chronic heart failure receive timely and high-quality palliative care. However, integrating palliative care is highly variable and dependent on decision-making and care models. This meta-synthesis aimed to examine health care professionals’ decision-making processes and explore factors impacting decisions to refer or deliver palliative care in chronic heart failure. The electronic databases SCOPUS, CINAHL, and Medline were searched. Included studies were those that reported health care professionals’ perceptions of palliative care in chronic heart failure through qualitative data collection, were written in English, and were peer-reviewed articles. Included articles were analysed using Thomas and Harden’s approach. The dual-process theory was used and applied a priori to organise the findings. The perception of palliative care as a transition and active treatment failure fit within the intuitive system of thinking in the dual-process theory. The theme that overlapped into both intuitive and analytical systems of thinking was acquiring patient and illness information themes reflecting the analytical system of thinking were professional role and experience, pre-existing decision pathways, and balancing viewpoints. This meta-synthesis identified factors influencing the decision-making process in referring patients with chronic heart failure to palliative care. The findings from this review highlight the need for further development of decision-making tools or facilitate guidelines to assist health care professionals’ shared decision-making to improve patient outcomes.</p

Hospital Service Use in the Last Year of Life for Individuals≥ 60 Years of Age Who Died of Heart Failure in Queensland

Background: Understanding health care utilisation by people with heart failure in the year preceding death can help inform health service development.Aim: To examine hospital-based service use in the last year of life by individuals aged ≥60 years old who died of heart failure in Queensland from 1 July 2008 to 31 December 2018. Methods: Linked Queensland Health administrative data containing information on hospitalisations, emergency department visits and death data were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision Australian Modification (ICD-10-AM) diagnostic codes. Results: There were 4699 individuals with an underlying cause of death of heart failure or cardiomyopathy, and a hospital episode in their last year of life. There were 25,592 hospital episodes - 89% (n=22,738) in an acute ward, and few (n=853, 3.4%) in a palliative care ward. The median (SD) number of hospital episodes in the last year of life was 3(1-283) (Figure 1). Of the 4699 individuals, 3459 had emergency department visit(s), presenting a total of 10,332 times with heart failure as the most common principal diagnosis (n=1919, 19%).Conclusion: Many individuals with heart failure receive care in acute or subacute hospital settings during the last year of life. A heart failure hospitalisation costs $5800, equating to over$148 million over ten years. Further research is needed to ensure timely palliative care is provided to people with heart failure in the last year of life