Achieving Universal Coverage Through Comprehensive Health Reform: The Vermont Experience

Provides an overview of Vermont's comprehensive health reform and the interim results of a two-year evaluation of its impact on the affordability of coverage and access to services, as well as its sustainability. Discusses lessons learned

Achieving Universal Coverage Through Comprehensive Health Reform: The Vermont Experience -- Report of Findings

Presents findings on the role of Vermont's health reform programs in increasing insurance coverage between 2005 and 2009. Examines changes by insurance type, contributing factors such as outreach campaigns, financial sustainability, and implications

An Assessment of Dialysis Provider's Attitudes towards Timing of Dialysis Initiation in Canada

Background: Physicians' perceptions and opinions may influence when to initiate dialysis. Objective: To examine providers' perspectives and opinions regarding the timing of dialysis initiation. Design: Online survey. Setting: Community and academic dialysis practices in Canada. Participants: A nationally-representative sample of dialysis providers. Measurements and Methods: Dialysis providers opinions assessing reasons to initiate dialysis at low or high eGFR. Responses were obtained using a 9-point Likert scale. Early dialysis was defined as initiation of dialysis in an individual with an eGFR greater than or equal to 10.5 ml/min/m 2 . A detailed survey was emailed to all members of the Canadian Society of Nephrology (CSN) in February 2013. The survey was designed and pre-tested to evaluate duration and ease of administration. Results: One hundred and forty one (25% response rate) physicians participated in the survey. The majority were from urban, academic centres and practiced in regionally administered renal programs. Very few respondents had a formal policy regarding the timing of dialysis initiation or formally reviewed new dialysis starts (N = 4, 3.1%). The majority of respondents were either neutral or disagreed that late compared to early dialysis initiation improved outcomes (85–88%), had a negative impact on quality of life (89%), worsened AVF or PD use (84–90%), led to sicker patients (83%) or was cost effective (61%). Fifty-seven percent of respondents felt uremic symptoms occurred earlier in patients with advancing age or co-morbid illness. Half (51.8%) of the respondents felt there was an absolute eGFR at which they would initiate dialysis in an asymptomatic patient. The majority of respondents would initiate dialysis for classic indications for dialysis, such as volume overload (90.1%) and cachexia (83.7%) however a significant number chose other factors that may lead them to early dialysis initiation including avoiding an emergency (28.4%), patient preference (21.3%) and non-compliance (8.5%). Limitations: 25% response rate. Conclusions: Although the majority of nephrologists in Canada who responded followed evidence-based practice regarding the timing of dialysis initiation, knowledge gaps and areas of clinical uncertainty exist. The implementation and evaluation of formal policies and knowledge translation activities may limit potentially unnecessary early dialysis initiation

Research Priorities for Achieving Healthy Marine Ecosystems and Human Communities in a Changing Climate

ABSTRACT: The health of coastal human communities and marine ecosystems are at risk from a host of anthropogenic stressors, in particular, climate change. Because ecological health and human well-being are inextricably connected, effective and positive responses to current risks require multidisciplinary solutions. Yet, the complexity of coupled social-ecological systems has left many potential solutions unidentified or insufficiently explored. The urgent need to achieve positive social and ecological outcomes across local and global scales necessitates rapid and targeted multidisciplinary research to identify solutions that have the greatest chance of promoting benefits for both people and nature. To address these challenges, we conducted a forecasting exercise with a diverse, multidisciplinary team to identify priority research questions needed to promote sustainable and just marine social-ecological systems now and into the future, within the context of climate change and population growth. In contrast to the traditional reactive cycle of science and management, we aimed to generate questions that focus on what we need to know, before we need to know it. Participants were presented with the question, "If we were managing oceans in 2050 and looking back, what research, primary or synthetic, would wish we had invested in today?" We first identified major social and ecological events over the past 60 years that shaped current human relationships with coasts and oceans. We then used a modified Delphi approach to identify nine priority research areas and 46 questions focused on increasing sustainability and well-being in marine social-ecological systems. The research areas we identified include relationships between ecological and human health, access to resources, equity, governance, economics, resilience, and technology. Most questions require increased collaboration across traditionally distinct disciplines and sectors for successful study and implementation. By identifying these questions, we hope to facilitate the discourse, research, and policies needed to rapidly promote healthy marine ecosystems and the human communities that depend upon them

Conservation management approaches to protecting the capacity for corals to respond to climate change: a theoretical comparison

Multiple anthropogenic impacts, including bleaching from climate change-related thermal stress, threaten coral reefs. Protecting coral capacity to respond to the increase in future thermal stress expected with climate change can involve (1) protecting coral reefs with characteristics indicative of greater resistance and resilience to climate change, and (2) reducing other anthropogenic impacts that are more likely to reduce coral resistance and resilience to climate change. Here, we quantitatively compare possible priorities and existing recommendations for protecting coral response capacity to climate change. Specifically, we explore the relative importance of the relevant dynamics, processes, and parameters in a size-structured model of coral and zooxanthellae ecological and evolutionary dynamics given projected future thermal stress. Model results with varying initial conditions indicate that protecting diverse coral communities is critical, and protecting communities with higher abundances of more thermally tolerant coral species and symbiont types secondary, to the long-term maintenance of coral cover. A sensitivity analysis of the coral population size in each size class and the total coral cover with respect to all parameter values suggests greater relative importance of reducing additional anthropogenic impacts that affect coral-macroalgal competition, early coral life history stages, and coral survivorship (compared with reproduction, growth, and shrinkage). Finally, model results with temperature trajectories from different locations, with and without connectivity, indicate that protection of, and connectivity to, low-thermal-stress locations may enhance the capacity for corals to respond to climate change