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Biomedical subjects

C Donaldson

Publications and source records attributed to C Donaldson.

At least 145 records · Page 8Linked to original sources
PubMed1989

Countering moral hazard in public and private health care systems: a review of recent evidence.

Within both publicly and privately financed health care systems different funding mechanisms have evolved, or have been proposed, to deal with the problem of 'moral hazard'. Moral hazard arises when financial incentives within the health care system lead to either inefficient demands for care by consumers or inefficient supply of care by providers. In this paper the problem of moral hazard is outlined in more detail, and different ways of countering moral hazard are reviewed in terms of three criteria: effect on patient utilisation of health services in general: effect on utilisation by different groups of patients; and effect on health status. It is concluded that evidence on different methods of funding health services can only be judged in the context of objectives. If the objectives of health care delivery are 'maintenance or improvement of health' and 'equal access for equal need' then charges of finance of care through health maintenance organisations both appear to be less favourable than 'free' care at the point of delivery whilst the latter is not necessarily more costly as a result. Research on other suggested alternatives is required, otherwise radical changes to health care financing in the UK will simply result in movement from one unproven system to another.

Capitation Fee↗
PubMed1989

Prolonging life at home: what is the cost?

This paper describes one of the first attempts at an economic evaluation of a community care initiative for elderly mentally infirm people and their carers. It is demonstrated that community support provided mainly through an innovative Family Support Unit (FSU) is almost three times more costly than that which would otherwise be provided. However, FSU support results in prolonged life at home for elderly mentally infirm people, thus saving costly long-term care beds. If life at home is preferable to long-term care, FSU care can be judged cost effective. However, regarding implementation of such schemes, cash-limited local authorities appear to be forced to take on schemes which, despite being cost effective when taking a broad range of resources into account, cost more than they save as far as the local authority itself is concerned.

Aged↗
PubMed1989

Development of lymphocytotoxic and platelet reactive antibodies: a prospective study in patients with acute leukaemia.

Lymphocytotoxic (LCT) and platelet reactive (PR) antibody (Ab) responses were serially determined in 49 patients with acute leukaemia. LCTAb were found in 20 patients and occurred in 13 patients with acute myeloid leukaemia and 7 patients with acute lymphoblastic leukaemia. Four differing patterns of LCTAb responses could be defined. Thirteen of 22 subjects showed marked reduction or loss of LCTAb. Indirect platelet immunofluorescence, measured by flow cytometry, provided the most convenient means of detecting PRAb which were found in 11 subjects and generally showed moderate or weak reactivity.

Adolescent↗
PubMed1989

The cost of diabetes.

This paper estimates the cost of diabetes in England and Wales in 1984 to be in excess of 259.5 million pounds. The costing methodology used follows the 'cost of illness' framework. This framework defines three elements for costing: direct, indirect and psychological, although the latter element is left out of the calculation because monetary valuations for this element have never been adequately estimated. Direct costs include resources used to prevent, detect, and treat diabetes. Indirect costs relate to the loss of productive output caused by absenteeism, early retirement, and premature mortality. The estimate which has been obtained is likely to be an underestimate because of the weaknesses and gaps in the data sets. The estimate of the total lost earnings from diabetes varied greatly according to the choice of absentee rate. If there was no significant difference between absenteeism in the diabetic community and the non-diabetic community then the cost of diabetes would be 259.5 million pounds. If on the other hand the diabetic community was prone to three times as much absenteeism as the non-diabetic community then the cost of diabetes would rise to 602.5 million pounds. The costs of diabetes as a subsidiary diagnosis are extremely difficult to identify. They have been estimated in this study to be 86 million pounds but this is thought to be an overestimate. Nevertheless the cost of diabetes is significant and thus the search for more efficient treatment regimens may reduce such costs as well as enhance the quality of life of the patients concerned.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1989

Paying general practitioners: shedding light on the review of health services.

This paper reviews evidence from recent research on the effects of different methods of remunerating general practitioners. Each method is examined in terms of patient use of health services in general, use of services by different groups in society and health outcome. Little is known about the effects of capitation as it currently exists in the UK, salaries or special payments for 'good practice', although evidence from British research is likely to be forthcoming on the last of these. Both health maintenance organizations and charges deter utilization, although little is known about the effect of this reduced demand. Furthermore, these two methods of financing health care appear to discriminate between members of society on lower and higher incomes in terms of both service use and health outcome. Fees for items of service provided tend to lead to unnecessary demands for fee yielding services by patients on the recommendation of their doctors. Although more evidence on different methods of remuneration is required, the importance of what is already known depends on the objectives of health care provision.

Capitation Fee↗
PubMed1988

Should QALYs be programme-specific?

One reason for the development of quality adjusted life years (QALYs) is to facilitate comparison across health care programmes in terms of productivity per unit of expenditure. However, some approaches to QALY measurement have also been developed using 'programme-specific' dimensions of quality of life. Using data, from a longitudinal trial of long-term care for elderly people, it is shown in this paper that an 'across-programme' method of quality of life measurement is less sensitive to changes in elderly people's health states than programme-specific methods more commonly used in the field of evaluating long-term care. It is argued that the same problem is likely to arise in evaluating care for other common chronic conditions like mental handicap, chronic conditions of childhood and terminal cancer. It is concluded that more work should be carried out comparing across-programme and programme-specific measures of quality of life, otherwise it will be difficult to determine whether certain groups in society are being discriminated against in health service resource allocation due to an insensitive across-programme measure of outcome.

Activities of Daily Living↗
PubMed1988

QALYS and long-term care for elderly people in the UK: scales for assessment of quality of life.

QALYs have developed in the UK as a tool for comparing the outcome of health care procedures in a single index over time. This tool can then be used, along with information on costs of procedures, in decision-making about health service resource allocation. It is shown that the attributes of disability and distress, on which QALYs are presently based in the UK, are insensitive to changes in the health status of elderly people in long-term care when compared to other measures of quality of life which are frequently used in studies of older people. Thus, if the use of QALYs increases, they should be based on attributes appropriate to the groups studied, otherwise certain groups may be discriminated against in health service resource allocation owing to the use of an insensitive measure of outcome.

Aged↗
PubMed1987

Applications of cost-benefit analysis to health care. Departures from welfare economic theory.

In applying the principles of cost-benefit analysis to real world problems of resource allocation particular care must be taken to ensure that the welfare economic theory which underlies the cost-benefit technique is adhered to. Major problems arise where costs and benefits are used interchangeably to represent the good and bad attributes of a programme. Furthermore, in the presence of mutually exclusive projects, focussing attention upon the net benefits (or cost-benefit ratios) of individual projects as opposed to the net benefits of the use of budgeted resources can lead to biased estimates of the shadow price of projects and, consequently, errors in analysts' conclusions. As a result, economic appraisals of individual projects are not directly relevant for choosing between mutually exclusive projects of different sizes. Both types of problem are illustrated by reference to both simple examples and published economic appraisals of health care techniques. Integer programming is proposed and demonstrated as a method of selecting between mutually exclusive projects.

Budgets↗
PubMed1987

Cost-benefit analysis: dealing with the problems of indivisible projects and fixed budgets.

The use of cost-benefit analysis in option appraisals in health care when the decision-maker is faced with indivisible projects and a fixed budget is examined. It is argued that the methods used to overcome the problem of indivisibilities, benefit-cost ratios and the net benefit method, are not suitable for choosing between alternative projects for two reasons. Firstly, the values of benefit-cost ratios are sensitive to the specification of costs and benefits, and the literature abounds with examples of averted costs being added to the benefits of a project or reduced benefits being interpreted as an additional (psychic) cost. We show that such erroneous specification can lead to a relatively inefficient project being accepted as efficient, and vice versa. Secondly, practical applications of CBA have been performed in the absence of budget constraints on available resources. We show that once budget constraints are recognised the shadow price of resources required to implement a project may be affected by the amount of resources remaining in the budget after implementation. Once the budget constraint is recognised, a project which initially appeared to be the most efficient can be rendered relatively inefficient. It is suggested that alternative uses of remaining (or residual) resources should be identified and evaluated, thus ensuring the maximisation of benefits from the use of an overall budget.

Budgets↗
PubMed1987

Economic appraisal of preventive dental techniques.

In this paper the principles and particular problems involved in applying economic appraisal to the evaluation of preventive dental care are investigated. There is no cost benefit analysis in the existing literature which gives a reliable indication of the relative efficiency of preventive and restorative dental techniques. This is because of difficulties involved in trying to attach monetary values to the benefits of programmes which are publicly provided. These difficulties are not resolved by representing the benefits of prevention by restorative costs averted. Although cost effectiveness analysis may seem a more straightforward method, it suffers from the inappropriateness of the dmft (or dmfs) statistic for measuring the relative effectiveness of restorative and preventive treatments. An alternative measure of dental health outcome is suggested which encompasses aspects of the quantity (in life years) and quality of teeth produced by restorative and preventive care. The full potential of economic appraisal of preventive dentistry will be realised only if such comprehensive measures of dental health outcome are produced. The task of producing such measures should involve dentists, consumers of dental care and health care researchers.

Cost-Benefit Analysis↗
PubMed1986

Preventive dentistry in a health centre: effectiveness and cost.

The clinical and economic effects of a programme of preventive dentistry for children in an inner-city health centre are compared with those for traditional restorative care. Reductions in the rate of dental caries are estimated to be 70% for children aged 4-6 after 4 years in the programme (dmft) and 85% for children aged between 7 and 10 years after 4 years (DMFT). The cost-effectiveness analysis on which the economic appraisal is based identifies the issue of differences in the quality of output as critical to choices between the two treatment regimes. The preventive programme was primarily intended for pre-school children; for this younger group, assumptions about the quality of the preventive outcome would have to value it at between 0.8 and 1.2 times the quality of the restorative outcome in order to make up the difference in cost between the two regimes. For 7-10 year olds, the 4-year analysis showed the preventive programme to be more costly than restorative care largely because of low rates of incremental change at these ages. These rates were partly influenced by the design of the study and partly by the eruption status of the permanent dentition across this age-group. There is a need for further study of measures of dental outcome which combine aspects of both the quality and length of life of teeth.

Child↗
PubMed1986

Determining value for money in day hospital care for the elderly.

This paper describes how a prospective evaluation of the costs and effectiveness of day hospital care for the elderly and its alternatives could be undertaken. The number of day hospitals for the elderly has grown from zero to slightly over 300 in just over 20 years. Despite this there is no study in the existing literature which gives an indication of whether day hospitals provide a reasonable return on this substantial investment. The best way of determining whether day hospitals are a better investment than alternative modes of care would be a randomized controlled trial involving comparison of subgroups of day hospital patients against similar subgroups utilizing alternative modes of care, the costing of each patient's consumption of services within the treatment mode in which they commence the study plus any subsequent use of other services over a predetermined time period, the collection of clinical, social and psychological outcome data (including data on dependency) for each subgroup before, during and at the end of the study period, and some measure of patients' and relatives' satisfaction with the treatment received.

Aged↗
PubMed1984

Hereditary neuraxial oedema in a Poll Hereford herd.

Cases of neuraxial oedema in a Poll Hereford herd were investigated and the pedigrees of affected calves determined. In all cases, and over no more than 3 generations, the pedigree led back to a common bull. Analysis of the herd breeding records supported an autosomal recessive mode of inheritance of the disease. Fractures of the femoral heads, acetabular cartilage and/ or bone, or both, were seen in some affected calves. This lesion was probably induced during birth or soon after, and the suggestion is made that such hip lesions could be regarded as highly suggestive of hereditary neuraxial oedmea of Herefords. The majority of calves showed clinical signs at birth, but 2 calves did not develop clinical signs until they were 2 days old.

Acetabulum↗
PubMed1983

Specific high-affinity binding and biologic action of retinoic acid in human neuroblastoma cell lines.

Neuroblastoma cells are a good model for neuronal development because of their ability to extend neurites in response to various stimuli, including retinoic acid. In the present experiments, we have examined five human neuroblastoma cell lines (LA-N-1, IMR-32, LA-N-5, SK-N-MC, and CHP-100) for the presence of cellular retinoic acid binding protein (CRABP), a receptor-like protein implicated in the molecular functioning of vitamin A. CRABP is identified and quantitated by sucrose gradient centrifugation, selective inhibition by the mercurial reagent p-chloromercuribenzene sulfonic acid (PCMBS), and saturation analysis. All five lines contain significant levels of cytosolic CRABP (2.5-7.5 pmol/mg of protein), which display typical properties of specific high affinity retinoic acid binding, a sedimentation coefficient of 2 S, and inhibition by PCMBS. Three of the lines (LA-N-1, IMR-32, and LA-N-5) are strongly growth inhibited by 1 microM retinoic acid in monolayer culture, whereas two (LA-N-1 and LA-N-5) undergo marked differentiation to a stellate, fusiform morphology with characteristic neurite outgrowths. The SK-N-MC and CHP-100 lines are relatively resistant to the antiproliferative effects of retinoic acid under these conditions. Nevertheless, all five lines are effectively inhibited by retinoic acid in their ability to form anchorage-independent colonies in soft agar. Thus, although CRABP is not necessarily correlated with growth inhibition in monolayer culture, it is associated with retinoic acid's ability to inhibit neuroblastoma colony formation in soft agar. More experiments will be required to determine if this effect on growth in soft agar reflects the putative ability of retinoic acid to convert tumorigenic neuroblastoma cell lines into the normal differentiated phenotype.

Carrier Proteins↗