Restructuring health care: rationing and compromise.
Explore the source record for details and available documents.
Biomedical Technology↗
SEARCH · Search PubMed
Results for “Allocation and cooperation”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Gamma globulin; status of availability for prevention of poliomyelitis.
A limited and temporary preventive effect has been noted for gamma globulin used under certain conditions. There is available a supply of gamma globulin which is inadequate to meet the demand with the methods of use indicated in the light of present knowledge. All supplies of gamma globulin have been placed under the responsibility of the Office of Defense Mobilization. Supplies allocated to the state of California are being made available to physicians through their local health departments on the basis of past and current incidence of poliomyelitis for use in protecting persons in household contact with patients with diagnosed cases. The most effective use of California's allocation of this material can be expected to prevent or modify approximately 40 cases on the basis of the past five-year experience (1947-1951). Parents, physicians and health officials must know the facts and cooperate to make the best of a difficult situation.
Biomedical Research↗
Logistics of a multinational population study.
The shaping of epidemiology as a clinical science prompted the perpetuation of large scale population studies aimed to determine causality and assessment of new therapeutical modalities. In order to achieve meaningful conclusions one has to rely on large masses of data, assembled by several teams of investigators in multi-geographical localities. The larger the number and diversity of participating groups, the more complex are the methodology and the final interpretation of outcome. A number of key principles in the undertaking of a long term joint population study are pointed out along 6 study stages: contemplation, planning, organization, data collection, analysis and outcome. The hypothesis has to be clearly formulated, financial resources mobilized, and lines of authority and communications strictly defined, before onset. Subsequently, the step by step routine of monitoring of the individual satellite centers, quality control and budget allocation, have to be established. The interpretation of the data may become final stumbling block since outcome is dependent on the quality of input and may be influenced by preconceived ideas of the investigators. Finally, the cooperative spirit behind the study may disappear once personalities and interests change. Hence, the future ownership of the data should be agreed upon before the conglomerate of data is split and fragmentated.
Data Collection↗
Comparison of the usefulness of bone marrow sections and smears in diagnosis of multiple myeloma.
Pretreatment bone marrow specimens from 273 patients with multiple myeloma (MM) and 148 patients with nonmyelomatous plasmacytosis were studied retrospectively to evaluate the usefulness of bone marrow sections and smears in establishing the diagnosis of MM. The combined findings in the sections and smears confirmed the clinical impression of MM in 83% of myeloma patients: in 59%, both sections and smears were diagnostic; in 17% the smears were diagnostic, the sections nondiagnostic; in 7% the sections, but not the smears, were diagnostic. In the remaining 17% of myeloma patients, both the sections and the smears failed to confirm the clinical impression of MM. Of the 148 patients with nonmyelomatous plasmacytosis, a pathologic over-diagnosis of MM was made in 2 patients. Reasons for these discrepancies, and problems relating to the validity of the current diagnostic criteria for MM are discussed. It is concluded that both bone marrow sections and smears should be examined when attempting the diagnose MM since either, by themselves, may not be diagnostic. Recommendations are made that immunoperoxidase staining methods be used in difficult cases, and that the marrow findings be correlated with clinical, laboratory, and radiologic findings prior to establishing the diagnosis of MM.
Amyloidosis↗
Regulation of UDPG pyrophosphorylase in Acetabularia mediterranea.
The kinetic properties of UDPG pyrophosphorylase (glucosyl-1-phosphate uridyl transferase, EC 2.7.7.9) suggest that it may play a key role in the regulation of metabolism in Acetabularia mediterranea. The enzyme-catalyzed reaction is readily reversible in vitro, and has been assayed in both directions. The enzyme shows substrate inhibition by UDPG and UTP at substrate concentrations in excess of 2 mM. The kinetic behavior of the enzyme is consistent with the hypothesis that it catalyzes an ordered bisubstrate biproduct reaction in which G-1-P is the leading substrate, and UTP is the leading product. A plot of initial velocity vs. PPi concentration is sigmoid, indicating a cooperative homotropic effect. PGAL inhibits the reaction in the direction: UTP + G-1-P leads to UDPG + PPi It has no effect on the reverse reaction. The responses of the enzyme may serve to regulate the allocation of G-1-P between anabolic and catabolic pathways.
Acetabularia↗
An "opting in" paradigm for kidney transplantation.
Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.
Altruism↗
A multidimensional model for treatment of child abuse: a framework for cooperation.
This article presents a model of child abuse treatment that allows practitioners to consider in a systematic way the problems that arise when different agencies need to work together on complex child abuse cases. The paper proposes five stages through which such cases routinely progress: interagency cross referral, joint case conference, allocation of treatment responsibilities, simultaneous treatment, and formal joint periodic reassessment. It argues that the problems at these five stages are major contributors to treatment breakdown. The clinician who analyzes the dynamics at each stage is better equipped to control the treatment process than the clinician who restricts his or her attention to dynamics that are occurring within one agency.
Child↗
The evolutionary biology of cryptic pregnancy: A re-appraisal of the "denied pregnancy" phenomenon.
Previous research on 'denied pregnancy', i.e. lack of subjective awareness of pregnancy until the end of gestation in pregnant women, is reviewed and reinterpreted in an evolutionary biological framework. Recent epidemiological studies show that this condition has a much higher incidence than previously thought (about 1:475). Very often, bodily symptoms of pregnancy (nausea, amenorrhea and abdomen swelling) are absent or greatly reduced, and neonates tend to be underweight; in many cases, pregnancy goes undetected also by relatives and physicians. Current explanations in the clinical literature are based on psychodynamic hypotheses about pregnancy-related unconscious conflicts; the lack of symptoms is accounted for by 'somatic denial'. I argue that such psychodynamic accounts are misguided for two reasons: (1) they rest on a failure to recognize the active biological role of the fetus in determining the course of pregnancy, and (2) they ignore the many levels of mother-fetus conflict over resource allocation described by biological theories of parent-offspring conflict. Here I propose to redefine this condition as 'cryptic pregnancy', and begin to explore its possible physiological correlates and evolutionary significance. In the light of parent-offspring conflict theory, cryptic pregnancy appears to reduce the costs of pregnancy, both energetic and ecological (mobility, dependence on kin/mate, etc.), thus favoring the mother at the expense of the fetus. Reduced hCG production and/or effectiveness is likely to be involved in the process. I propose and discuss three nonexclusive evolutionary hypotheses to account for this phenomenon: (1) cryptic pregnancy could be a nonadaptive outcome of conflict resolution processes over resource allocation in pregnancy, possibly related to minor disruptions of genomic imprinting mechanisms. (2) Cryptic pregnancy could result from missed spontaneous abortions of low-quality fetuses. (3) Finally, cryptic pregnancy could be an adaptive pattern of 'forced cooperation' between mother and fetus in stressful or threatening ecological circumstances, as suggested by the reported association with elevated psychosocial stress. In case of reduced survival probability, both mother and fetus would benefit if the mother reduced investment in pregnancy in order to maximize her chances of surviving and reaching delivery.
Abortion, Missed↗
Gemcitabine plus vinorelbine yields better survival outcome than vinorelbine alone in elderly patients with advanced non-small cell lung cancer. A Southern Italy Cooperative Oncology Group (SICOG) phase III trial.
OBJECTIVE: This phase III study was aimed at evaluating whether the addition of gemcitabine (G) to vinorelbine (V) could improve the survival and quality of life (QoL) of elderly patients with advanced NSCLC. PATIENTS AND METHODS: Patients with advanced NSCLC, aged >or=70 years, were randomly allocated to receive V 30 mg/m(2) on days 1 and 8 every 3 weeks or G 1200 mg/m(2) plus V 30 mg/m(2) on days 1 and 8 every 3 weeks. Survival was the main end point of the study. The estimated sample size was 120 patients per arm, but an interim analysis of survival was planned on the first 60 patients per arm. RESULTS: In May 1999, an interim analysis was performed with the survival data of the first 120 eligible patients (V(arm)=60, G+V(arm)=60). Forty-nine patients had stage IIIB disease and 71 patients stage IV disease, median potential follow-up of 14 months (range; 3-22), 93 patients had died (G+V(arm)=41, V(arm)=52). Median survival time (MST) was 29 weeks and projected 1-year survival was 30% in the G+V(arm); these values were 18 weeks and 13% in the V(arm). At multivariate Cox analysis, the risk of death in the G+V(arm) compared with V(arm) was 0.48 (95% C1=0.29-0.79; P<0.01). Combination therapy was also associated with a clear delay in symptom and QoL deterioration. The ORR was 22 and 15% in the G+V and V(arms), respectively. Toxicity was not irrelevant in both arms. CONCLUSIONS: G+V treatment is associated with a significantly better survival than V alone in elderly NSCLC patients. The magnitude of the difference justifies the early closure of the study. The G+V regimen is now the SICOG reference regimen in this type of patients.
Aged↗
Profit and loss analysis for an intensive care unit (ICU) in Japan: a tool for strategic management.
BACKGROUND: Accurate cost estimate and a profit and loss analysis are necessary for health care practice. We performed an actual financial analysis for an intensive care unit (ICU) of a university hospital in Japan, and tried to discuss the health care policy and resource allocation decisions that have an impact on critical intensive care. METHODS: The costs were estimated by a department level activity based costing method, and the profit and loss analysis was based on a break-even point analysis. The data used included the monthly number of patients, the revenue, and the direct and indirect costs of the ICU in 2003. RESULTS: The results of this analysis showed that the total costs of USD 2,678,052 of the ICU were mainly incurred due to direct costs of 88.8%. On the other hand, the actual annual total patient days in the ICU were 1,549 which resulted in revenues of USD 2,295,044. However, it was determined that the ICU required at least 1,986 patient days within one fiscal year based on a break-even point analysis. As a result, an annual deficit of USD 383,008 has occurred in the ICU. CONCLUSION: These methods are useful for determining the profits or losses for the ICU practice, and how to evaluate and to improve it. In this study, the results indicate that most ICUs in Japanese hospitals may not be profitable at the present time. As a result, in order to increase the income to make up for this deficit, an increase of 437 patient days in the ICU in one fiscal year is needed, and the number of patients admitted to the ICU should thus be increased without increasing the number of beds or staff members. Increasing the number of patients referred from cooperating hospitals and clinics therefore appears to be the best strategy for achieving these goals.
Accounting↗
Comparison of the study groups in the National Cooperative Dialysis Study and a description of morbidity, mortality, and patient withdrawal.
Explore the source record for details and available documents.
Clinical Trials as Topic↗
Assessing risk for major depression on patients selected for percutaneous transluminal coronary angioplasty: is it a worthwhile venture?
We hypothesized that a prior history of a major depressive disorder would not compromise the efficacy of percutaneous transluminal coronary angioplasty (PTCA), a coronary revascularization procedure, in improving quality of life and health status when comparing patients with no previous history. To determine the utility of screening for risk for depression in heart patients scheduled for PTCA, 190 patients were administered a two-item depressive disorders screener prior to PTCA and the SF-36 and Seattle Angina Questionnaire prior to and 6 months post procedure. Results reveal that while those with no prior history of depression had statistically better quality of life and health status outcomes than those with a probable past depression, (P <.05), the clinically meaningful differences as determined by effect size scores showed that those susceptible to recurrent depression benefited from PTCA as well as, and on some measures better than those with no previous history. Prescreening patients at probable risk for a depression is not a valid or helpful enterprise if the purpose is to develop intervention strategies for improving outcome post PTCA. Screening out patients based on history of depression may in fact lead to an inequitable allocation of resources and have no major benefit in enhancing quality of life and improving health status.
Adult↗
Polymorphisms of the vitamin D receptor, infant growth, and adult bone mass.
Family and twin studies have demonstrated a strong genetic component to the development of peak bone mass. Early fetal and infant environment has also been shown to influence bone mass through an effect on skeletal size and mineral content. We report a retrospective study that has examined whether early infant growth is regulated by genetic factors shown to be associated with bone mass. We have determined the vitamin D receptor (VDR) gene alleles for 66 women (mean age 65.5 years) on whom detailed birth records were available. There was a statistically significant trend (P = 0.04) for VDR genotype against weight at the age of 1 year, with the "tt" homozygote group having 7% higher weight. We conclude that early fetal or infant environment may interact with an individual's underlying genotype to program early skeletal growth, and that this may track through later life to influence adult characteristics. Further prospective studies are required, however, to fully clarify the precise environmental and genetic mechanisms underlying these findings.
Absorptiometry, Photon↗
Developing leaders for advanced life support: evaluation of a training programme.
AIM: To evaluate the effectiveness of a leadership development seminar introduced into the Resuscitation Council (UK) Advanced Life Support (ALS) Provider course. METHODS: Observational assessments of leadership performance during cardiac arrest scenarios before and after a leadership seminar. RESULTS: The leadership training programme significantly improved candidates leadership performance in the training situation. CONCLUSION: A formal leadership development programme should be introduced into advanced life support courses.
Advanced Cardiac Life Support↗
Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina.
We evaluated long-term survival after coronary-artery bypass grafting in 686 patients with stable angina who were randomly assigned to medical or surgical treatment at 13 hospitals and followed for an average of 11.2 years. For all patients and for the 595 without left main coronary-artery disease, cumulative survival did not differ significantly at 11 years according to treatment. The 7-year survival rates for all patients were 70 per cent with medical treatment and 77 per cent with surgery (P = 0.043), and the 11-year rates were 57 and 58 per cent, respectively. For patients without left main coronary-artery disease, the 7-year rates were 72 and 77 per cent in medically and surgically treated patients, respectively (P = 0.267), and the 11-year rates were 58 per cent in both groups. A statistically significant difference in survival suggesting a benefit from surgical treatment was found in patients without left main coronary-artery disease who were subdivided into high-risk subgroups defined angiographically, clinically, or by a combination of angiographic and clinical factors: (1) high angiographic risk (three-vessel disease and impaired left ventricular function)--at 7 years, 52 per cent in medically treated patients versus 76 per cent in surgically treated patients (P = 0.002); at 11 years, 38 and 50 per cent, respectively (P = 0.026); (2) clinically defined high risk (at least two of the following: resting ST depression, history of myocardial infarction, or history of hypertension)--at 7 years, 52 per cent in the medical group versus 72 per cent in the surgical group (P = 0.003); at 11 years, 36 versus 49 per cent, respectively (P = 0.015); and (3) combined angiographic and clinical high risk--at 7 years, 36 per cent in the medical group versus 76 per cent in the surgical group (P = 0.002); at 11 years, 24 versus 54 per cent, respectively (P = 0.005). Survival among patients with impaired left ventricular function differed significantly at 7 years (63 per cent in the medical group versus 74 per cent in the surgical group [P = 0.049]) but not at 11 years (49 versus 53 per cent). The surgical treatment policy resulted in a nonsignificant survival disadvantage throughout the 11 years in subgroups with normal left ventricular function, low angiographic risk, and low clinical risk, and a statistically significant disadvantage at 11 years in patients with two-vessel disease.(ABSTRACT TRUNCATED AT 400 WORDS)
Angina Pectoris↗
Plasma fibrinopeptide A levels in patients with acute myocardial infarction treated with alteplase. Correlation with concomitant heparin, coronary artery patency, and recurrent ischemia. The European Cooperative Study Group.
BACKGROUND: Fibrin generation during and after therapy with alteplase may depend on the level of concomitant anticoagulation. The hypothesis that fibrinopeptide A (FPA) levels, as markers of ongoing in vivo fibrin formation, correlate with the angiographic and clinical outcome of thrombolysis is tested. METHODS AND RESULTS: Serial plasma FPA levels were determined in 334 patients of the randomized European Cooperative Study Group trial comparing heparin versus placebo plus alteplase and aspirin in patients with acute myocardial infarction. Median FPA levels (with the 10th to 90th percentiles) were 21 ng/ml (2-390 ng/ml) before treatment in placebo-allocated patients (n = 166) and increased to 49 (15-580), 34 (4-320), 27 (2-240), 29 (2-430), and 30 (3-390) ng/ml after 0.75, 3, 12, 24, and 36 hours, respectively. In heparin-allocated patients (n = 168), median baseline FPA values were 18 ng/ml (2-210 ng/ml) and decreased to 6 (1-110), 5 (1-75), 5 (1-60), 7 (1-100), and 10 (1-170) ng/ml at corresponding time points (p less than 0.0001 for the difference at each time point). Adequate anticoagulation, defined as no activated partial thromboplastin time value below twice the pretreatment value at 3, 12, 24, and 36 hours after initiation of treatment, was obtained in 48 patients assigned to heparin. It was associated with normal median FPA levels (less than or equal to 4 ng/ml) at all time points compared with 12 (2-80), 16 (2-240), and 15 (2-240) ng/ml at 12, 24, and 36 hours, respectively, in heparin-assigned but inadequately anticoagulated patients (n = 102, p less than 0.001 for each time point). In the heparin-treated group, median FPA values tended to be lower at all time points in patients with patent vessels than in patients with occluded arteries, but the difference was significant only at 24 hours (p = 0.04). FPA levels did not correlate with clinically apparent recurrent ischemia or with left ventricular thrombosis on two-dimensional echocardiography. CONCLUSIONS: During and after thrombolytic therapy with alteplase, the enhanced fibrin generation is suppressed by sustained concomitant anticoagulation with intravenous heparin. Adequate anticoagulation warrants individual titration of the heparin dose. High plasma FPA levels 24 hours after alteplase therapy are specific but insensitive markers of vessel occlusion in anticoagulated patients. They do not correlate with clinical outcome.
Coronary Vessels↗
Response of depressive symptoms to nortriptyline, phenelzine and placebo.
The effects of nortriptyline, phenelzine, and placebo on 13 symptoms of depression were compared in 75 patients, aged 55 or over, who were suffering from major depression. Nortriptyline and phenelzine were more effective than placebo in treating depression mood, guilt feelings, suicidal ideation, agitation, anxiety, loss of energy, and a.m. diurnal variation of mood. Nortriptyline was better than phenelzine or placebo in improving middle/late insomnia. Most of the symptoms did not show significant improvement until the fourth week of treatment.
Aged↗
Intergovernmental issues raised by the national health planning program.
Raab uses the National Health Planning and Resources Development Act of 1974(P.L.93-641)which designated state and substate regional planning agencies, as a departure for discussion of a larger issue: federalism. Administration of the law has raised issues about the allocation of power among national, state and local governments. The author tries to set this question in historical context by tracing the history of U.S. intergovernmental relations and highlighting key issues. He focuses on two perspectives of federalism: cooperative and competitive relations between governments. From this survey, Raab draws three conclusions: conflict has become "inevitable" as governments pursue their own objectives in administering national grants-in-aid; state and local officials have grown more concerned with administrative structure than the substance of policy; and the growth of lobbies for state and local governments has reduced the prospect of conflict.
Conflict, Psychological↗