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Healthcare rationing for people with learning disabilities.

The recent case of Jo, a Down's Syndrome child who was initially refused a heart and lung transplant (BBC TV 1996) has raised the issue of rationing health care. This article discusses the issues surrounding rationing and looks critically at some of the definitions and assumptions it is based upon. The historical and the future impact of various types of rationing upon people with learning disabilities is highlighted. The author argues that people with learning disabilities would benefit from a more explicit rationing system to enable decisions, made possibly on prejudiced grounds, at least to be challenged.

Attitude to Health↗

[Rationing in surgery and high-tech medicine].

There has been much debate about cost-cutting in health care. In this context, the term rationing means that acceptable services and measures with proven benefit are subject to limited allocation (or complete refusal thereof) due to a shortage of resources. After an introductory discussion about the "terminology" of rationing, achievements in premium health care will be critically elucidated in this regard. Chapter 2 focuses on the question of whether age is a valid criterion for the rationing of surgical care. Chapter 3 critically analyses the "societal solution" to the rationing problem. The way to solve society's tendency to become insatiable (pleonexia) is the same as the way to solve the shortage of resources, i.e. by "circumspection" or "moderation" on the part of each individual (sophrosyne).

Cost Control↗

Managed care and efficient rationing.

Widespread dissatisfaction with managed care has led to calls for major reform and consumer protection. Although some have concluded that managed care backlash is simply a result of too much rationing, we propose an alternative view that focuses on the nature of services eliminated by managed care. In particular, we point out that managed care rations services largely without regard to consumer preferences. We question whether managed care's emphasis on supply-side control of moral hazard is consistent with the principles of efficient rationing. Further research on the nature of provider and consumer rationing decisions is needed to inform the design of supply-side and demand-side incentives that will lead to an efficient allocation of services.

Consumer Behavior↗

Rationing health care: its impact and implications for hematology-oncology.

Rationing of health care in the United States currently exists via the covert mechanism of restricting significant segments of medical care for many of those who cannot afford it. Provision of universal health care would necessitate explicit rationing of certain interventions and technologies, even though an individual could afford them. The British and Canadian experiences provide lessons from which America can profit, and the Oregon health plan is an experiment in this direction. The progressive "graying" of America has raised the question of the need for intergenerational charity as a form of rationing. The implications of these rationing plans would result in a major restructuring of the practice of hematology-oncology.

Canada↗

Physicians and rationing.

Current cost-containment pressures seem to be leading American health care into a world of rationing. Many people have urged that we resist rationing on the grounds that it would compromise the integrity of the patient-physician relation. I shall argue that rationing is in fact both inevitable and appropriate, but the world of rationing is one in which the role of the moral physician involves complex balancing of moral obligations.

Cost Control↗

Empirically based criteria for rational suicide: a survey of psychotherapists.

This qualitative study was designed to develop a set of empirically based criteria for rational suicide by asking psychotherapists to define "rational suicide." Data analysis revealed three components of a rational suicide: (1) the presence of an unremittingly hopeless condition (eight examples provided), (2) a suicidal decision made as a free choice, and (3) the presence of an informed decision-making process (five elements listed). It is suggested that the criteria may possibly be used in assessing the rationality of suicidal clients.

Attitude of Health Personnel↗

Rationing of hospital services in the Australian health system.

This article reports on the rationing in the Australian hospital sector and explains why it has been undertaken. It also briefly overviews the Australian health system in order to provide a necessary background for the issue of rationing itself. Rationing of hospital services has occurred because governments in Australia have limited hospital sector resources trying to ensure the containment of their health budgets. The resources available to hospitals have been insufficient to ensure that the supply of services meets the demand for such services. Therefore, in order to contain hospital budgets rationing has been required. Medicare, the universal health insurance system, assures that access to public hospital services is on the basis of clinical needs. However, due to the federal nature of government in Australia, the available services are determined by health system structural interrelationships and direct government regulation. For example, services provided in the community sector, and funded by the Commonwealth government, are prime candidates for being removed from the hospital sector by State/Territory governments. Similarly, expensive services with a wide range of usage are candidates for regulation to contain costs.

Australia↗

The effects of rational and irrational self-verbalizations on performance efficiency and levels of anxiety.

Investigated the effects of rational vs. irrational belief systems (as measured by the Ellis Irrational Values Scale) and rational vs. irrational self-verbalizations on levels of anxiety and persistence on a performance task. Ss (N = 40) were instructed to assemble a virtually insolvable task call Soma. The variables of interest were how long each S would persist on this task and how much anxiety (as measured by the A-State portion of the State-Trait Anxiety Inventory) was aroused in working on this task. Following a baseline trial trying to solve Soma, Ss were assigned to either a rational or irrational self-talk condition and were led to believe that such self-talk would help in a second attempt to solve Soma. In line with cognitive models of psychology, it was found that rational self-talk Ss showed a significant decrease in levels of state anxiety compared to irrational self-talk Ss in attempting to solve Soma in the second trial. Contrary to cognitive models of psychology, scores obtained from the EIVS and the A-Trait portion of the STAI were not found to be related to persistence.

Achievement↗

[Supplementation of the amino acid composition of protein-rich wheat with protein concentrates and L-lysine in rations for laying hens. 4. Effect of various rearing diets on crude protein, fat and ash contents of the utilizable and nonutilizable parts of carcasses of slaughter hens].

The present paper is concerned with the effects of four rations of varying composition (fed to pullets from the eighth to the twenty-second week of life) on the composition of the carcasses of laying hens at the end of a 52-week trial. Ration 1 served as a control; ration 2 contained 68% protein-rich wheat as a protein carrier, 2% extracted soybean meal. 4% fish meal; the two other rations contained only 94% protein-rich wheat with or without addition of 2% lysine. The mean live-weights of the animals for slaughter were: 1792 g +/- 71 g; 1760 g +/- 78 g; 1701 g +/- 92 g; and 1655 +/- 102 g, respectively. The mean portion of edible parts (heart, liver, stomach, fatty tissue, follicles, flesh) of the 104 carcasses was 61.6% +/- 3.0%. The edible parts contained (mean values): crude protein, 18.0% +/- 2.0%; raw fat, 22.8% +/- 5.7%; and crude ash, 1.02% +/- 0.16%. The values calculated for the bonefree, uneatable parts (to be used as feed) were: crude protein, 16.2% +/- 0.7%; raw fat, 8.7% +/- 1.5%; and crude ash, 3.45% +/- 0.32%. The ash content of the edible parts is increased by lysine-rich diets. The rearing as well as the feeding during the laying period exerted no targeted effect on the crude protein and raw fat contents of the carcasses. The fat content of the carcass is determined by the consumption of energy.

Aging↗

Magnesium, calcium and phosphorus contents in daily food rations in primary school children: questionnaire and analytic studies.

Aims of the performed studies included working out a technique of determining representative rations on the basis of questionnaire studies on school children in Wielkopolska west region of Poland. The reconstructed representative daily food rations provided grounds for analytic studies. The studies were performed in the four seasons of the year. The studied food rations failed to cover the recommended daily intake of Mg and Ca. On the other hand, the daily intake of P transgressed the food norms. The inadequate Ca to Mg and Ca to P ratios were interpreted as deserving special concern when confronted with the market situation in Poland and as creating particular health hazards for the studied school children. The employed statistical analysis demonstrated that the suggested technique of determining representative rations may be employed in evaluation of Mg, Ca and P intake.

Adolescent↗

Teaching rational prescribing: a new clinical pharmacology curriculum for medical schools.

In most U.S. and Canadian medical schools, pharmacology is taught during the preclinical year 2 of the 4-year-long curriculum. This is despite the fact that medical school graduates and residency directors have identified teaching rational therapeutics as a priority. Hence, we have developed a core curriculum in clinical pharmacology for 4th-year medical students that builds on the core principles of rational therapeutics described by Nierenberg 10 years ago (Nierenberg, DW. Clin Pharmacol Ther 1990; 48:606-610). Here we report on our 3-year experience teaching this course, which addresses the following teaching objectives: to teach medical students on how to (1) critically evaluate medications; (2) obtain a complete medication history including herbal and over-the-counter medications; (3) apply pharmacokinetic principles to clinical practice; (4) recognize and report adverse drug events and interactions; (5) optimize pain management; (6) recognize and treat substance abuse and poisoning; and (7) prescribe rationally regardless of prescribing environment. Student assessment was in the form of multiple-choice and formative oral examinations, which were validated against the clinical part of the U.S. medical licensing examination. The course significantly increased the student rating of clinical pharmacology teaching measured by a national survey of U.S. medical school graduates. We conclude that this course may be useful for teaching rational prescribing to medical students. With the guidance and educational material provided by this article, a successful implementation of such a course should be possible in most medical schools.

Curriculum↗

Ergonomic effects of a management-based rationalization in assembly work - a case study.

Due to unsatisfactory productivity, a large company in the Swedish manufacturing industry decided to rationalize their assembly system. The intended rationalization comprised several changes with deliberate ergonomic implications. The main aim of the present study was to evaluate the impact of the rationalization on the physical work load of the operators. The work load was assessed before and after the changes using expert observations, company records and direct technical measurements. The results indicate that the intervention led to only minor changes in muscle load, body postures and movement patterns. Several of the planned initiatives were never implemented, e.g. teaching the workers multiple skills and designing work stations at which a major part of the assembly sequence could be performed. This was mainly due to a policy revision caused by changes in the market situation. In spite of the company's original intentions, the revised production system contained only minor ergonomic improvements. Thus, the realization of the ergonomic potential in a rationalization seems to depend on management culture, as well as factors outside the company.

Journal Article↗

A de novo model of rational pharmacotherapy training: the interns' perspective.

Background: Poor prescribing habits can lead to ineffective and unsafe treatment, exacerbation or prolongation of illness, distress and harm to the patient, and higher costs. Rational pharmacotherapy training is very important for reducing poor prescribing practices, especially in developing countries. The aim of this study was to evaluate interns' satisfaction with a rational pharmacotherapy training program at the Department of Internal Medicine of our university. Methods: Rational pharmacotherapy training, designed by the WHO Action Program on Essential Drug Advice, was the subject of the study. Interactive learning methods, such as small group discussions and role-playing, were used as training methods. All of the interns in the class of 2003 participated in the training during their internal medicine internship period. Perceptions of the interns were collected via a 15-item feedback questionnaire. A 5-point Likert scale was used for scoring, and mean values were calculated for every item. Results: Mean values of all items were higher than 4, except for the control item. Interns' satisfaction with the training differed significantly in the third week, which focused on the physician-patient relationship. Interns suggested that this training should be performed in other classes and apprenticeship periods. Conclusions: This was the first training program in Turkey. Rational pharmacotherapy training should be integrated into the medical curriculum and performed using a multidisciplinary approach.

Journal Article↗

Rationality, universality, and individuality in a functional conception of theory.

In the present paper we reflect on some critically important issues in theory construction from the point of view of a practicing scientist. The starting point is to suggest the need for a minimal base of common agreement on the role of successfully working theories. It is proposed that scientific knowledge is not composed of singular facts but rather of relational structures connecting facts. Useful theories are both receptive and productive. Theories provide models, i.e., idealised representations of reality, expressed, in their most developed phases, in a mathematically formalised language. We further focus on the notions of rationality and universality, and show that these are mutually related and actually inseparable. Universality means description of observable phenomena in terms of universally valid laws that are essentially of a rational character, i.e., stated in terms of relational invariants preserved in variant, contingent conditions. Law-like components of a theory are universal by definition, not given by circumstances, and rational by their form, not by their content. Facts, on the other hand, are irrational elements unless they can be derived from law-like relations of another theory. Relational definition of rationality is self-consistent and independent from vaguely defined notions like 'reason'. Pertinent to studies of human nature, including psychophysiology, is the problem of individuality. To reconcile the claim of universality with an adequate account of unique individuality, we advocate a 'distributed nomothesis', distinguishing first-order laws ruling in an individual 'idioversum', from the higher-order, universal laws. Idioversal laws play the role of 'facts' in construction of universal theories.

Algorithms↗

Rational engineering of enzyme stability.

During the past 15 years there has been a continuous flow of reports describing proteins stabilized by the introduction of mutations. These reports span a period from pioneering rational design work on small enzymes such as T4 lysozyme and barnase to protein design, and directed evolution. Concomitantly, the purification and characterization of naturally occurring hyperstable proteins has added to our understanding of protein stability. Along the way, many strategies for rational protein stabilization have been proposed, some of which (e.g. entropic stabilization by introduction of prolines or disulfide bridges) have reasonable success rates. On the other hand, comparative studies and efforts in directed evolution have revealed that there are many mutational strategies that lead to high stability, some of which are not easy to define and rationalize. Recent developments in the field include increasing awareness of the importance of the protein surface for stability, as well as the notion that normally a very limited number of mutations can yield a large increase in stability. Another development concerns the notion that there is a fundamental difference between the "laboratory stability" of small pure proteins that unfold reversibly and completely at high temperatures and "industrial stability", which is usually governed by partial unfolding processes followed by some kind of irreversible inactivation process (e.g. aggregation). Provided that one has sufficient knowledge of the mechanism of thermal inactivation, successful and efficient rational stabilization of enzymes can be achieved.

Biotechnology↗

Ration formulation using linear programming.

A combination spreadsheet-LP ration formulation program offers tremendous advantages for dairy nutritionists. The spreadsheet format provides the framework for flexibility in describing feeds and in formulating a realistic and practical ration. The LP module can solve for a complicated set of nutrient requirements to give a relatively well-balanced ration. This "first-cut" ration can then be reworked in the spreadsheet mode to meet the needs of the individual farm based on other biologic and management considerations.

Animal Feed↗

Evaluation of rational antibiotic use.

The emergence of antibiotic resistant bacteria is a major problem throughout the world and a rational use of antibiotics is therefore very important. This study was performed to estimate the appropriateness of antimicrobial drug use in Celal Bayar University Hospital in Manisa. The data of all inpatients (n=937) between October and December 1998 were collected according to the Kunin and Jones criteria. Of the patients, 16.6% (n=156) were receiving antibiotics, and in 63.5, 23.0 and 13.5% of these, a single, two and three agents were used, respectively. The purpose of antibiotic use was for prophylaxis in 23.9%, as an empiric decision in 71.4% and for therapeutic culture-based reasons in 4.7%. The rate of rational antibiotic use was 45.7% and it was statistically higher in those patients from whom specimens had been taken for culture than in patients receiving prophylactic or empiric antibiotics. On medical wards, rational antibiotic usage was 55.1%, while it was 26.3% in surgical wards (P<0.0001). The low rate of appropriate antibiotic use in our university hospital reflects the urgent need of rationalization.

Anti-Bacterial Agents↗

Comparison of in vivo selection and rational design of heterodimeric coiled coils.

To investigate how electrostatic interactions restrict the associations of coiled coils, we improved a heterodimeric coiled coil (WinZip-A1B1) by in vivo selection and, alternatively, by rational design. Selection from libraries encoding variable edge (g and e) residues enriched g/e' ion pairs, but the optimum selected heterodimers unexpectedly retained two predicted repulsive g/e' pairs. The best genetically selected heterodimer displayed similar thermodynamic stability and specificity as a rationally designed dimer with predicted ion pairs at all edge positions. This rationally designed pair, however, was less effective than the best genetically selected pair in mediating dimerization in vivo. Thus, the effects of predicted charge pairs depend on sequence context, and complementary charges at the edge positions rationalize only a fraction of the sequences that form stable, specific coiled coils.

Cell Division↗