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Long-term care (LTC) must be carefully delineated when expenditures are compared across countries because how LTC services are defined and delivered differ in each country. LTC’s objectives are to compensate for functional decline and mitigate the care burden of the family. Governments have tended to focus on the poor but Germany opted to make LTC universally available in 1995/1996. The applicant’s level of dependence is assessed by the medical team of the social insurance plan. Japan basically followed this model but, unlike Germany where those eligible may opt for cash benefits, they are limited to services. Benefits are set more generously in Japan because, prior to its implementation in 2000, health insurance had covered long-stays in hospitals and there had been major expansions of social services. These service levels had to be maintained and be made universally available for all those meeting the eligibility criteria. As a result, efforts to contain costs after the implementation of the LTC Insurance have had only marginal effects. This indicates it would be more efficient and equitable to introduce public LTC Insurance at an early stage before benefits have expanded as a result of ad hoc policy decisions.

Objective To determine risk factors for childhood overweight that can be identified during the first year of life to facilitate early identification and targeted intervention. Design Systematic review and meta-analysis. Search strategy Electronic database search of MEDLINE, EMBASE, PubMed and CAB Abstracts. Eligibility criteria Prospective observational studies following up children from birth for at least 2 years. Results Thirty prospective studies were identified. Significant and strong independent associations with childhood overweight were identified for maternal pre-pregnancy overweight, high infant birth weight and rapid weight gain during the first year of life. Meta-analysis comparing breastfed with non-breastfed infants found a 15% decrease (95% CI 0.74 to 0.99; I2=73.3%; n=10) in the odds of childhood overweight. For children of mothers smoking during pregnancy there was a 47% increase (95% CI 1.26 to 1.73; I2=47.5%; n=7) in the odds of childhood overweight. There was some evidence associating early introduction of solid foods and childhood overweight. There was conflicting evidence for duration of breastfeeding, socioeconomic status at birth, parity and maternal marital status at birth. No association with childhood overweight was found for maternal age or education at birth, maternal depression or infant ethnicity. There was inconclusive evidence for delivery type, gestational weight gain, maternal postpartum weight loss and ‘fussy’ infant temperament due to the limited number of studies. Conclusions Several risk factors for both overweight and obesity in childhood are identifiable during infancy. Future research needs to focus on whether it is clinically feasible for healthcare professionals to identify infants at greatest risk.

Background: While many studies have demonstrated positive associations between childhood obesity and adult metabolic risk, important questions remain as to the nature of the relationship. In particular, it is unclear whether the associations reflect the tracking of body mass index (BMI) from childhood to adulthood or an independent level of risk. This systematic review aimed to investigate the relationship between childhood obesity and a range of metabolic risk factors during adult life. Objective: To perform an unbiased systematic review to investigate the association between childhood BMI and risk of developing components of metabolic disease in adulthood, and whether the associations observed are independent of adult BMI. Design: Electronic databases were searched from inception until July 2010 for studies investigating the association between childhood BMI and adult metabolic risk. Two investigators independently reviewed studies for eligibility according to the inclusion/exclusion criteria, extracted the data and assessed study quality using the Newcastle–Ottawa Scale. Results: The search process identified 11 articles that fulfilled the inclusion and exclusion criteria. Although several identified weak positive associations between childhood BMI and adult total cholesterol, low-density lipo protein-cholesterol, triglyceride and insulin concentrations, these associations were ameliorated or inversed when adjusted for adult BMI or body fatness. Of the four papers that considered metabolic syndrome as an end point, none showed evidence of an independent association with childhood obesity. Conclusions: Little evidence was found to support the view that childhood obesity is an independent risk factor for adult blood lipid status, insulin levels, metabolic syndrome or type 2 diabetes. The majority of studies failed to adjust for adult BMI and therefore the associations observed may reflect the tracking of BMI across the lifespan. Interestingly, where adult BMI was adjusted for, the data showed a weak negative association between childhood BMI and metabolic variables, with those at the lower end of the BMI range in childhood, but obese during adulthood at particular risk.

ObjectiveSpinal muscular atrophy (SMA) is a neuromuscular disorder that manifests with motor deterioration and respiratory complications. The paradigm of care is shifting as disease-modifying therapies including nusinersen, onasemnogene abeparvovec and risdiplam alter the disease trajectory of SMA. The objective of this study was to explore caregivers’ experiences with disease-modifying therapies for SMA.DesignQualitative study including semistructured interviews with caregivers of children with SMA who received disease-modifying therapies. Interviews were audio recorded, transcribed verbatim, coded and analysed using content analysis.SettingThe Hospital for Sick Children (Toronto, Canada).ResultsFifteen family caregivers of children with SMA type 1 (n=5), type 2 (n=5) and type 3 (n=5) participated. There were two emerging themes and several subthemes (in parentheses): (1) inequities in access to disease-modifying therapies (variable regulatory approvals, prohibitively expensive therapies and insufficient infrastructure) and (2) patient and family experience with disease-modifying therapies (decision making, hope, fear and uncertainty).ConclusionThe caregiver experience with SMA has been transformed by the advent of disease-modifying therapies. Consistent and predictable access to disease-modifying therapies is a major concern for caregivers of children with SMA but is influenced by regulatory approvals, funding and eligibility criteria that are heterogenous across jurisdictions. Many caregivers described going to great lengths to access therapies, highlighting issues related to justice, such as equity and access. This diverse population reflects contemporary patients and families with SMA; their broad experiences may inform the healthcare delivery of other emerging orphan drugs.

Autistic adults in need of long-term services and supports spend months on waiting lists before receiving such services through Medicaid. Data from a state-wide survey of adults and their caregivers on a waiting list for autism waivers suggest that the majority have unmet needs for functional skills services (63.6%), employment or vocation services (62.1%), and mental and behavioral health services (52.8%). Almost a third require case management services (28.3%). Predictors of greater service need are African American race and the number of physical and behavioral health diagnoses. Predictors of greater service receipt were employment status, housing type, and school enrollment; there was lower service receipt for African American race, Hispanic ethnicity, over age 21 years, and college completion.

The U.S. Social Security Disability Insurance (DI) program has grown dramatically over the last 20 years in size and expense. This growth poses significant risks to the finances of the DI program and the broader Social Security system, and raises troubling questions as to whether the program is being misused by claimants. This article first provides an overview of the Disability Insurance program, describing who qualifies for the program, how an individual applies for benefits and how the level of benefits is determined. Next, we summarize the factors responsible for the growth in the DI rolls and discuss how the characteristics of DI recipients have changed as a result. We then explore the extent of moral hazard in the DI program and the effectiveness of the screening process in distinguishing meritorious from nonmeritorious claims. Finally, we identify the challenges that the DI program creates for Social Security finances and Social Security reform, and discuss potential reforms to the DI program.

This research evaluated the feasibility of actigraphy to measure sleep and physical activity in children (ages 2–8 years) with autism spectrum disorder (ASD). We also explored associations between sleep and physical activity. Validated screening measures established eligibility. Questionnaires, diaries, and 5 days and 5 nights of actigraphy monitoring were used to collect data. Of the 32 children enrolled, 27 (84.4%) completed actigraphy monitoring. Based on the median steps per day, children with high physical activity had lower total sleep time and more disruptive behaviors than children with low physical activity. Findings support the feasibility of using actigraphy to measure sleep and physical activity in children with ASD. Larger studies are needed to evaluate interactions of physical activity on sleep in this population.

The Pooled Cohort Equations (PCEs), developed by the American Heart Association (AHA) and American College of Cardiology, have been widely used since 2013 to estimate 10-year atherosclerotic cardiovascular disease (ASCVD) risk and guide statin therapy. Recently, the AHA introduced the Predicting Risk of CVD EVENTs (PREVENT) equations to improve ASCVD risk estimation. However, the effect of using PREVENT instead of PCEs on risk classification and statin eligibility remains unclear. This retrospective cohort study analyzed 261,303 UK Biobank participants, aged 40 to 69 years, who were free from cardiovascular disease and not on statin therapy. The PCEs and the base PREVENT equations were used to estimate 10-year ASCVD risk, categorize risk levels, and determine statin eligibility based on a common risk threshold of 7.5%. The median 10-year ASCVD risk was 5.2% (2.2%, 10.6%) using the PCEs and 3.5% (1.8%, 5.8%) with the PREVENT equations. The PREVENT equations classified 14.0% of participants as high-risk (ASCVD risk >7.5%), compared to 36.9% classified by PCEs. Among participants classified as intermediate-risk by PCEs, 75.3% were reclassified as low-risk by PREVENT. The proportion of individuals eligible for statin use by the PREVENT equation was 19.9%, and by the PCEs was 40.7%. The corresponding difference was 20.8% (95% confidence intervals [CI]: 20.6% to 20.9%). More men (33.0% [95% CI: 32.7% to 33.3%]) than women (11.5% [95% CI: 11.3% to 11.7%]) and more individuals in the older age group (60 to 69 years: 34.0% [95% CI: 33.7% to34.3%]) than in the younger age group (40 to 49 years: 3.5% [95% CI: 3.3% to 3.6%]) would not be recommended for statin consideration with the PREVENT equations. In conclusion, based on the common risk threshold of 7.5%, replacing the PCEs with the base PREVENT equation would reduce statin eligibility in the UK Biobank participants by ∼20%, especially among men and older adults.

The use of eligibility for a free lunch as a measure of a student's socioeconomic status continues to be a fixture of quantitative education research. Despite its popularity, it is unclear that education researchers are familiar with what student eligibility for a free lunch does (and does not) represent. The authors examine the National School Lunch Program, which is responsible for certifying students as eligible for a free lunch, and conclude that free lunch eligibility is a poor measure of socioeconomic status, which suffers from important deficiencies that can bias inferences. A table characterizing key strengths and weaknesses of variables used as measures of socioeconomic status is provided to facilitate comparisons.

The Carnegie effect is the harm inherited wealth does to a recipient’s work effort. Carnegie effect estimates are few, reflecting that such effects are hard to trace. Most previous studies rely on data from limited-size surveys. We use information from administrative data covering the entire Norwegian population, enabling an examination of the heterogeneity of the Carnegie effect. Estimation results show significant reductions in labor supply for recipients of large inheritances. We find that Carnegie effects differ according to transfer size, the recipient’s age and eligibility for other transfer programs, and the existence of new heirs in the family chain.