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PubMed1990

Resources, the family and voluntary euthanasia.

Ethnological studies show that the care which societies are able to provide for their old people depends largely on available resources. However, the concept of resource depends on contemporary requirements and expectations. Modern families still try to look after their old people, but increasing longevity is making this more difficult. There is a finite ability of populations, however wealthy, to support dependent members. Resources provided to look after old people must necessarily be subtracted from those available for the other, still more important dependent group, the children, with potentially disastrous results in underfunding of social support and education. The sociobiological theory of inclusive fitness emphasizes the importance of the ways in which family members interact to help each other and try to ensure their genetic survival, even if this involves sacrificing their own interests and occasionally, their lives. Many old people do not wish for further longevity after they have become too disabled to be of service to their families, and would prefer to see limited resources being used for the young. In the USA, loss of autonomy of patients and their families owing to the practice of defensive medicine has resulted in the development of the 'living will', a legal document in which people can specify in advance what treatment they wish to accept in the event of life threatening illness. It is to be hoped that improved understanding of family relationships will make this generally unnecessary in the future and that, unless specified to the contrary, families will be allowed to decide about treatment for members who are unable to decide for themselves.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1983

Health care technology and the inevitability of resource allocation and rationing decisions. Part I.

Increasingly, it is recognized that resources available to meet health care needs are limited. Recently, this has been evidenced by reductions in federally funded health care programs and the leveling off of research funds made available to the National Institutes of Health. The problem of severely constrained resources is likely to become more acute, given new medical technology and the high cost of medical care. It is now apparent that both resource allocation and resource-rationing decisions will become inevitable, since not all persons with catastrophic or complicated medical conditions will be able to benefit from medical technology. While the careful assessment of health care technology can conceivably increase the efficiency of the health care delivery system, the methods by which allocation and rationing decisions are made must be improved. In doing so, it will ultimately be essential for this society to come to grips with life and death issues in a manner to which it is not accustomed.

Biomedical Research↗
PubMed2002

Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure.

BACKGROUND: Case management is believed to promote continuity of care and decrease hospitalization rates, although few controlled trials have tested this approach. OBJECTIVE: To assess the effectiveness of a standardized telephonic case-management intervention in decreasing resource use in patients with chronic heart failure. METHODS: A randomized controlled clinical trial was used to assess the effect of telephonic case management on resource use. Patients were identified at hospitalization and assigned to receive 6 months of intervention (n = 130) or usual care (n = 228) based on the group to which their physician was randomized. Hospitalization rates, readmission rates, hospital days, days to first rehospitalization, multiple readmissions, emergency department visits, inpatient costs, outpatient resource use, and patient satisfaction were measured at 3 and 6 months. RESULTS: The heart failure hospitalization rate was 45.7% lower in the intervention group at 3 months (P =.03) and 47.8% lower at 6 months (P =.01). Heart failure hospital days (P =.03) and multiple readmissions (P =.03) were significantly lower in the intervention group at 6 months. Inpatient heart failure costs were 45.5% lower at 6 months (P =.04). A cost saving was realized even after intervention costs were deducted. There was no evidence of cost shifting to the outpatient setting. Patient satisfaction with care was higher in the intervention group. CONCLUSIONS: The reduction in hospitalizations, costs, and other resource use achieved using standardized telephonic case management in the early months after a heart failure admission is greater than that usually achieved with pharmaceutical therapy and comparable with other disease management approaches.

Aged↗
PubMed1989

Hospital resource consumption and outcome. Route of admission and age for hospitalized otolaryngology patients.

Hospitals and physicians face new payment mechanisms that provide incentives to study health policy, management, and economics. The purpose of this study was to analyze hospital resource consumption and outcome based on age and the route of hospital admission (emergency [ER] vs nonemergency [non-ER]). We analyzed all adult otolaryngology hospital admissions (N = 1589) during a three-year period (1985 through 1987) to a large northeastern academic medical center. Hospital resource consumption, measured by hospital length of stay and total hospital cost per patient, rose with age for ER and non-ER admissions. Severity of illness, clinical resource utilization, and mortality demonstrated these same characteristics. Diagnosis related group prospective hospital payment generated financial risk for ER admissions and elderly patients. Analysis demonstrated ER admission as more predictive of subsequent hospital resource consumption and outcome with changes in age compared with non-ER admission. Our findings suggest that in the future physicians and hospitals may find that age and the route of admission may be useful in stratifying patients regarding cost and outcome.

Academic Medical Centers↗
PubMed2003

Does it matter who you are or what you gain? An experimental study of preferences for resource allocation.

Using an experimental conjoint-analysis like approach, preferences for resource allocation were studied. An interactive survey was developed which was published in the World Wide Web. A convenience sample of undergraduate students participated in the study. Subjects were confronted with nine pairwise scenarios describing hypothetical patient groups in need of life-saving treatments. The patient groups presented differed in terms of their health-related lifestyle, socioeconomic status, age, life expectancy, quality of life after treatment and whether they had received extensive medical care in the past. Participants were asked to allocate a finite budget to each patient group. All attributes used in this study significantly influenced respondents' preferences on how to allocate the budget between patient groups. The general importance of attributes used in the QALY approach is supported by this study with quality of life being a central criterion. The distributional patterns observed were, however, different from those expected when rigorously adhering to the QALY framework: In only a very small fraction of allocations subjects distributed the entire budget strictly on the patient group expecting the highest QALY gain. The vast majority of responders was willing to trade efficiency for a more equal distribution of resources. The approach described can be used to analyze the importance people place on different attributes in resource allocation decisions and to study preferences for the final distribution of resources.

Age Factors↗
PubMed1985

The distribution and impact of health resource availability in China.

Since 1949, China's progress in mortality reduction has far exceeded that experienced by other developing countries with comparable levels of national income. This achievement has taken place in the context of a development strategy oriented, in part, to the elimination of the worst aspects of poverty. Using recent cross-section data, this paper provides a statistical assessment of the extent to which health resources are evenly distributed in contemporary China, and the degree to which improvements in health resource availability may account for the observed variation in mortality levels. Contrary to expectation, the analysis finds that substantial inequalities do remain in the distribution of health resources, and that these differentials are principally associated with levels of urban income and urbanization. However, these differences in health resource availability do not appear to explain the significant variation which also persists in mortality levels, a finding consistent with the results of similar analyses for developed countries.

China↗
PubMed2006

The impact of anti-tumour necrosis factor therapy for rheumatoid arthritis on the use of other drugs and hospital resources in a pragmatic setting.

BACKGROUND: Anti-tumour necrosis factor (anti-TNF) therapy has been an important development for the treatment of rheumatoid arthritis (RA) but the impact of its delivery on hospital resources in still emerging. AIMS: We audited the effect of starting anti-TNF on the use of other anti-rheumatic therapies and hospital resources in a routine secondary care setting. METHODS: A retrospective study of resource use before and after anti-TNF was conducted. Hospital records of 54 RA patients were studied and data taken from the time of commencing anti-TNF to 1 October 2004 and an equal time period prior to commencing anti-TNF. Identical data were collected for 54 controls not on anti-TNF. Relevant figures were extrapolated to per annum rates. Results were analysed using two-factor ANOVAs comparing the pre- versus post-anti-TNF period. Cases on intravenous (IV) versus subcutaneous (SC) anti-TNF were also compared in separate ANOVAs. RESULTS: Mean duration of anti-TNF therapy was 17.04 months (range 3.60-42.36). Mean pre- and 3-months post-anti-TNF Disease Activity Scores (DAS28) were 6.93 and 3.88, respectively. Cases were more likely than controls to be on oral prednisolone pre- and post-anti-TNF. Methylprednisolone requirement, number of disease-modifying anti-rheumatic drugs (DMARDs), telephone helpline contacts and duration as an inpatient reduced significantly post-anti-TNF. Day case admissions increased but outpatient appointments decreased only in cases on IV anti-TNF. CONCLUSIONS: In a pragmatic setting, anti-TNF therapy led to reduced need for steroid injections and other DMARDs, as well as reductions in use of several hospital resources. Wider replication of these findings will be important for planning delivery.

Adult↗
PubMed2001

Associations of income with self-reported ill-health and health resources in a rural community sample of Austria.

OBJECTIVES: Three levels of health indicators (1) self-reported ill-health, (2) internal health resources, and (3) external health resources were analysed in relation to a four-category house-hold income distribution in order to describe possible social gradients. The particular aim of this study was to obtain information on the association of income data with self-reported ill-health. METHODS: This cross-sectional study was based on a health survey. The sample represents around 10% of the rural population of some communities in Styria, randomly selected from the population registry. Interview data was collected from 3781 participants aged 15 years and older, 1559 males and 2222 females. RESULTS: The results show that individuals from lower house-hold income classes are disadvantaged with regard to indicators of ill-health, internal and external health resources. Overall, the link between low income and poor health is highly consistent within our data. CONCLUSIONS: Considering our results we conclude that internal and external health resources are as unequally distributed over income levels as health outcome indicators.

Adolescent↗
PubMed2004

A complex systems model approach to quantified mineral resource appraisal.

For federal and state land management agencies, mineral resource appraisal has evolved from value-based to outcome-based procedures wherein the consequences of resource development are compared with those of other management options. Complex systems modeling is proposed as a general framework in which to build models that can evaluate outcomes. Three frequently used methods of mineral resource appraisal (subjective probabilistic estimates, weights of evidence modeling, and fuzzy logic modeling) are discussed to obtain insight into methods of incorporating complexity into mineral resource appraisal models. Fuzzy logic and weights of evidence are most easily utilized in complex systems models. A fundamental product of new appraisals is the production of reusable, accessible databases and methodologies so that appraisals can easily be repeated with new or refined data. The data are representations of complex systems and must be so regarded if all of their information content is to be utilized. The proposed generalized model framework is applicable to mineral assessment and other geoscience problems. We begin with a (fuzzy) cognitive map using (+1,0,-1) values for the links and evaluate the map for various scenarios to obtain a ranking of the importance of various links. Fieldwork and modeling studies identify important links and help identify unanticipated links. Next, the links are given membership functions in accordance with the data. Finally, processes are associated with the links; ideally, the controlling physical and chemical events and equations are found for each link. After calibration and testing, this complex systems model is used for predictions under various scenarios.

Conservation of Natural Resources↗
PubMed2003

Biodiversity conservation and resource tenure regimes: a case study from northeast Cambodia.

The management of tropical protected areas is a contentious issue in resource management and often leads to an unproductive polarization of viewpoints supporting either "protectionist" or "sustainable development" paradigms. This paper argues for a context-driven approach whereby effective management requires inputs from both paradigms in different situations. A key element of context is understanding long-practiced resource tenures and their ability to meet future conservation and livelihood goals. Different types of tenure arrangements are often required for different resources. This approach is illustrated by analysis of Virachey National Park in NE Cambodia. This park encompasses part of the ancestral territory of ethnic Brao people, who rely upon swidden agriculture, fish, terrestrial wildlife, and various nontimber forest products (NTFPs) for their livelihoods. These people have developed a mix of resource tenure regimes to promote sustainable use and to maximize local benefits. In the face of contemporary pressures, some of these traditional approaches are effective, while others are not. The paper suggests avenues for building on long-established management practices of the Brao to achieve park management goals while enhancing the welfare of the Brao people. A mix of private ownership, common property management, and central government involvement may be required to maximize benefits to local people and ensure long-term protection of biodiversity.

Agriculture↗
PubMed2004

Community participation in natural resources management: reality or rhetoric? Lessons learnt from the Kasanka Game Management Area (GMA) communities, Serenje District, Zambia.

In the developing world, the term 'participation' has in recent years become a household word in the same way that 'democracy' or 'gender' have. Development agencies are demanding increased participation in their programmes. The use of the word or its application has become a centre of debate. Due to the difficulties involved in measuring 'participation' or indeed determining levels at which participation should take place, who participates and when, many 'doubting Thomases' have questioned its effectiveness. It has, however been acknowledged in many areas that popular participation changes policies and enhances management and governance. In complex issues of natural resources management, participatory techniques have helped communities develop collective responsibilities towards management of their resources and projects. This paper discusses the complexities of community participation in natural resources management, ranging from interrelations among stakeholders to resource ownership based on the experiences in the Kasanka Game Management Area (KGMA).

Animals↗
PubMed2005

Improved allocation of HIV prevention resources: using information about prevention program production functions.

To allocate HIV prevention resources effectively, it is important to have information about the effectiveness of alternative prevention programs as a function of expenditure. We refer to this relationship as the "production function" for a prevention program. Few studies of HIV prevention programs have reported this relationship. This paper demonstrates the value of such information. We present a simple model for allocating HIV prevention resources, and apply the model to an illustrative HIV prevention resource allocation problem. We show that, without sufficient information about prevention program production functions, suboptimal decisions may be made. We show that epidemiologic data, such as estimates of HIV prevalence or incidence, may not provide enough information to support optimal allocation of HIV prevention resources. Our results suggest that good allocations can be obtained based on fairly basic information about prevention program production functions: an estimate of fixed cost plus a single estimate of cost and resulting risk reduction. We find that knowledge of production functions is most important when fixed cost is high and/or when the budget is a significantly constraining factor. We suggest that, at the minimum, future data collection on prevention program effectiveness should include fixed and variable cost estimates for the intervention when implemented at a "typical" level, along with a detailed description of the intervention and detailed description of costs by category.

Canada↗
PubMed2005

Parental awareness of health and community resources among immigrant families.

OBJECTIVES: To examine the association between parental immigrant status and awareness of health and community resources to help address common family problems. METHODS: Using the 1999 National Survey of America's Families, a survey of the health, economic, and social characteristics of children and adults, bivariate and multivariate analyses were conducted on 35,938 children to examine the relationship between parents' immigrant status (U.S.-born citizens, naturalized citizens, and noncitizens) and their responses to questions about their awareness of specific health and community resources. RESULTS: Compared to U.S.-born citizens, noncitizens were at the highest risk of not being aware of health and community resources for most outcomes, followed by naturalized citizens. The services of which noncitizens were most likely to be unaware were places to get help for family discord, child care issues, and family violence. Multivariate analyses indicate that parental race/ethnicity, education level, employment status, and child age were other significant independent risk factors. CONCLUSIONS: Immigrant parents are at particularly high risk of alienation from systems of health care and support services that are available to low-income and other vulnerable populations in the United States. These findings clearly document disparate awareness among parents of different immigrant status. Community and health resources should reach out to immigrant populations, in linguistically and culturally appropriate ways, to alert them to the availability of their services.

Adolescent↗
PubMed1989

Hospital costs and resource characteristics for cardiothoracic surgical hospital deaths.

No major changes in the federal Medicare diagnostic-related group (DRG) prospective hospital payment system have been implemented by the United States Congress. We analyzed hospital resource consumption for 1,567 cardiothoracic surgical patients by outcome (ie, survivors versus nonsurvivors). The 76 patients who died had a much greater intensity of hospital resource utilization and represented a substantial financial risk under DRG pricing schemes compared with the 1,491 survivors. Only patients who died within 1 week of admission to the hospital generated a financial surplus under DRGs. A long hospital stay for nonsurvivors produced a substantial deficit (patients with a stay greater than 60 days generated a $154,433 loss per patient). The cardiothoracic patients admitted on an emergency basis who died tended to have a shorter length of stay and represented a lower financial risk under DRGs compared with patients admitted on a nonemergency basis who died. Among nonsurvivors, patients referred for cardiothoracic surgical procedures from other clinical services had lower resource utilization and financial risk under DRGs compared with nonreferrals. These data suggest significant inequities in the current DRG prospective payment system vis-à-vis cardiothoracic surgical patients who die. Variables predictive of greater hospital resource utilization by outcome included a longer hospital stay, nonemergency admission, and admission directly to the cardiothoracic surgical service. Methods to improve the equity of DRG payment vis-à-vis cardiothoracic surgical nonsurvivors should be implemented in the future.

Adolescent↗
PubMed1993

A proposal for the establishment of the National Center for Phytogenetic Resource Conservation in the Venezuelan Republic.

The conservation of biodiversity, a valuable natural resource, is considered essential. In the face of continued threats to this resource the establishment of a National Center for Phytogenetic Resource Conservation in Venezuela is proposed. The proposed center would have the following main objectives: inventory of resources, establishment of a plant gene bank, basic ecological research, promotion of cultivation of useful but endangered species, promotion of national and international information-exchange, and protection of natural habitats. The organizational structure of the proposed center is outlined.

Conservation of Natural Resources↗
PubMed2005

Resource use, costs, and quality of life among patients in the multinational Valsartan in Acute Myocardial Infarction Trial (VALIANT).

BACKGROUND: In a multinational clinical trial, valsartan was statistically not inferior to captopril in reducing mortality and cardiovascular morbidity after myocardial infarction (MI) in patients with signs of heart failure and/or left ventricular dysfunction. We conducted a prospective economic evaluation to compare within-trial resource use, costs, and quality of life in patients receiving valsartan, captopril, or both after MI. METHODS: We assigned country-specific unit costs to resource use data for 14703 patients and measured health-related quality of life in a subset of 4524 patients. We used the nonparametric bootstrap method to compare rates of resource use and costs, and a piecewise linear mixed-effects regression analysis to compare longitudinal measures of quality of life. RESULTS: There were no significant differences in rates of resource use between the valsartan and captopril groups. During an average follow-up of 2 years, total costs for patients receiving valsartan were significantly higher than for patients receiving captopril (USD 14103 vs USD 13038; 95% CI USD 369-USD 1875). The cost differential was caused primarily by the cost of the study medications (USD 1056 for valsartan vs USD 165 for captopril; 95% CI USD 867 to USD 912). Quality of life did not differ significantly between groups. CONCLUSIONS: For most patients at high risk after MI, the availability of generic captopril confers a cost advantage over valsartan because of lower medication costs. The difference will be smaller or nonexistent in settings where brand-name ACE inhibitors are prescribed.

Ambulatory Care↗
PubMed2004

The effect of montelukast versus usual care on health care resource utilization in children aged 2 to 5 years with asthma.

BACKGROUND: Limited clinical data are available on the long-term effects of asthma controller therapy on the utilization of health care resources in pediatric patients with asthma. OBJECTIVE: The objective of this study was to compare the effects of long-term treatment with montelukast and usual care on health care resource use in children with asthma. METHODS: Pediatric patients aged 2 to 5 years with asthma who had completed a 3-month, double-blind, double-dummy clinical trial comparing montelukast 4 mg and placebo were asked to participate in an open-label, controlled extension study comparing montelukast 4 mg and usual care. Usual care was defined as cromolyn or inhaled corticosteroid therapy Health care resource utilization was measured in terms of oral corticosteroid use and numbers of physician visits, emergency department visits, and hospitalizations. RESULTS: Of 618 patients who completed the primary phase of the study, 516 (83.5%) participated in the extension study Data from 506 patients (302 without previous asthma maintenance therapy, 204 with) were included in the analysis. During the extension phase, patients who received montelukast and had not used previous asthma maintenance therapy were followed for a mean of 329.5 days; those who received usual care and CONCLUSION: In this open-label study, pediatric patients aged 2 to 5 years with mild to moderate persistent asthma receiving long-term therapy with montelukast had similar rates of asthma-related health care resource utilization compared with those receiving usual care with cromolyn or inhaled corticosteroids.

Acetates↗
PubMed2003

Pandemic influenza-implications for critical care resources in Australia and New Zealand.

OBJECTIVES: To quantify resource requirements (additional beds and ventilator capacity), for critical care services in the event of pandemic influenza. MATERIALS AND METHODS: Cross-sectional survey about existing and potential critical care resources. Participants comprised 156 of the 176 Australasian (Australia and New Zealand) critical care units on the database of the Australian and New Zealand Intensive Care Society (ANZICS) Research Centre for Critical Care Resources. The Meltzer, Cox and Fukuda model was adapted to map a range of influenza attack rate estimates for hospitalisation and episodes likely to require intensive care and to predict critical care admission rates and bed day requirements. Estimations of ventilation rates were based on those for community-acquired pneumonia. RESULTS: The estimated extra number of persons requiring hospitalisation ranged from 8,455 (10% attack rate) to 150,087 (45% attack rate). The estimated number of additional admissions to critical care units ranged from 423 (5% admission rate, 10% attack rate) to 37,522 (25% admission rate, 45% attack rate). The potential number of required intensive care bed days ranged from 846 bed days (2 day length of stay, 10% attack rate) to 375,220 bed days (10 day length of stay, 45% attack rate). The number of persons likely to require mechanical ventilation ranged from 106 (25% of projected critical care admissions, 10% attack rate) to 28,142 (75% of projected critical care admissions, 45% attack rate). An additional 1,195 emergency ventilator beds were identified in public sector and 248 in private sector hospitals. Cancellation of elective surgery could release a potential 76,402 intensive care bed days (per annum), but in the event of pandemic influenza, 31,150 bed days could be required over an 8- to 12-week period. CONCLUSION: Australasian critical care services would be overwhelmed in the event of pandemic influenza. More work is required in relation to modelling, contingency plans, and resource allocation.

Australia↗