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PubMed2002

The equivalence of numbers: the social value of avoiding health decline: an experimental Web-based study.

BACKGROUND: Health economic analysis aimed at informing policy makers and supporting resource allocation decisions has to evaluate not only improvements in health but also avoided decline. Little is known however, whether the "direction" in which changes in health are experienced is important for the public in prioritizing among patients. This experimental study investigates the social value people place on avoiding (further) health decline when directly compared to curative treatments in resource allocation decisions. METHODS: 127 individuals completed an interactive survey that was published in the World Wide Web. They were confronted with a standard gamble (SG) and three person trade-off tasks, either comparing improvements in health (PTO-Up), avoided decline (PTO-Down), or both, contrasting health changes of equal magnitude differing in the direction in which they are experienced (PTO-WAD). Finally, a direct priority ranking of various interventions was obtained. RESULTS: Participants strongly prioritized improving patients' health rather than avoiding decline. The mean substitution rate between health improvements and avoided decline (WAD) ranged between 0.47 and 0.64 dependent on the intervention. Weighting PTO values according to the direction in which changes in health are experienced improved their accuracy in predicting a direct prioritization ranking. Health state utilities obtained by the standard gamble method seem not to reflect social values in resource allocation contexts. CONCLUSION: Results suggest that the utility of being cured of a given health state might not be a good approximation for the societal value of avoiding this health state, especially in cases of competition between preventive and curative interventions.

Adult↗
PubMedDate not supplied

Impact of pharmacist-operated general medicine chronic care refill clinics on practitioner time and quality of care.

OBJECTIVE: To assess the impact of pharmacist-operated refill clinics on practitioner (physician/physician assistant) time. Secondary objectives included assessment of disease state control, drug acquisition costs, and human resource allocation. DESIGN: The study ran from October 1, 1993 through January 31, 1994. At one clinic the pharmacist performed chart review only and did not see the patient. At the second site the pharmacist also interviewed the patient. The pharmacist used no treatment algorithms. Practitioner and pharmacist time before and after implementation of the refill clinics was measured on 3 consecutive days of normal clinic operation. SETTING: Two state correctional facilities. PATIENTS: The study population consisted of patients receiving chronic care who were observed during regular clinic hours. MAIN OUTCOME MEASURES: We evaluated pharmacist and practitioner time before and after pharmacist involvement. Hypertension was the only disease state yielding sufficient numbers for statistical analysis. We used a two-tailed paired t-test with the priori level set at 0.05. We also evaluated the number of patients with disease state control before and after clinic implementation, drug acquisition costs, and human resource allocation. RESULTS: The refill clinic pharmacist reduced practitioner time commitment in both clinics. The greatest impact on practitioner time was found in the interview clinic. Quality of care was maintained equally between the two clinics, with a positive impact on human resource allocation. CONCLUSIONS: In the managed care environment, pharmacist-run refill clinics can decrease practitioner time commitment allowing reallocation of human resources while maintaining current quality of care.

Adult↗
PubMed2006

Ethical issues in pandemic planning.

In the event of an influenza pandemic, many ethical issues will arise in terms of health risks, resource allocation, and management decisions. Planning decisions may be controversial, such as rationing of antivirals, resource allocation (including hospital beds and vaccinations), occupational risk, rostering of staff, responsibilities of health care workers, quarantine measures, and governance issues. A clear ethical framework is needed to enable understanding of the decision-making process and optimise acceptance of decisions by health care workers and other members of an affected community. Planning decisions need to start being examined now, and will require input from a broad group of experts: health care providers, infrastructure managers, lawyers, ethicists, public health physicians, and community members. The process will need to be open, honest and dynamic.

Australia↗
PubMed2000

Dollars, debts and duties: lessons from funding Australian general practice.

This study investigated changes in resource allocation and activities of Australian Divisions of General Practice associated with new funding procedures which link monies to nominated outcomes. The study involved analysis of annual reports and strategic plans, and semistructured telephone interviews with key personnel from 27 divisions of general practice. The main outcome measures were: number of activities in various nominated health areas; total and median expenditure per activity in each area; and methods of resource allocation. Despite a modest increase in funding to the total general practice divisions program over the two year period, expenditure decreased in the National Health Priority Areas of mental health, diabetes, cardiovascular disease, injuries and cancer. There was increased expenditure in the priority area of immunisation, which received dedicated funding. There was greatly increased expenditure in the areas of information technology and services to GPs (including continuing medical education, professional development and workforce issues). The ease of defining and measuring outcomes influenced the choice of activities. In 1996, activities were linked to formal needs analyses in approximately 20 per cent of cases. The most frequent driving force for projects was enthusiastic GPs. In 1998, resource allocation decisions were more explicitly linked to formal needs analyses; however, the standard of the needs analyses varied widely between divisions. Changes in funding procedures which use nominated outcomes as the major accountability mechanism may produce unexpected, and unintended results, including significantly decreased expenditure in areas with outcomes which are hard to define and measure but which are important for health improvement.

Journal Article↗
PubMed2002

Opinions of Swedish citizens, health-care politicians, administrators and doctors on rationing and health-care financing.

OBJECTIVE: To compare the views of citizens and health-care decision-makers on health-care financing, the limits of public health-care, and resource allocation. DESIGN: A postal survey based on a randomized sample of adults taken by the national registration and stratified samples of health-care politicians, administrators, and doctors in five Swedish counties. PARTICIPANTS: A total number of 1194 citizens (response rate 60%) and 427 decision-makers (response rate 69%). RESULTS: The general public have high expectations of public health-care, expectations that do not fit with the decision-makers' views on what should be offered. To overcome the discrepancy between demand and resources, physicians prefer increased patient fees and complementary private insurance schemes to a higher degree than do the other respondents. Physicians take a more favourable view of letting politicians on a national level exert a greater influence on resource allocation within public health-care. A majority of physicians want politicians to assume a greater responsibility for the exclusion of certain therapies or diagnoses. Most politicians, on the other hand, prefer physicians to make more rigorous decisions as to which medical indications should entitle a person to public health-care. CONCLUSIONS: The gap between public expectations and health-care resources makes it more important to be clear about who should be accountable for resource-allocation decisions in public health-care. Significant differences between physicians' and politicians' opinions on financing and responsibility for prioritization make the question of accountability even more important.

Adult↗
PubMed2006

Lack of patients? A hypothesis for understanding discrepancies between hospital resources and productivity.

BACKGROUND: Despite a substantial increase in hospital resources, increased hospital admissions and out-patient visits, long waiting lists have been a significant problem in Norwegian health care. A detailed analysis of the development in resource allocation and productivity at St. Olavs University Hospital in central Norway was therefore undertaken. METHODS: Resource allocation and patient volume was analysed during the period 1995 to 2001. Data were analysed both for emergency and elective admissions as well as outpatient visits specified into new referrals and follow-up consultations. RESULTS: Full time employee equivalents for doctors and nurses increased by 36.6% and 25.9%, respectively, and all employees by 28.1%. However, admitted patients, outpatient consultations and surgical procedures only increased by 10%, 15% and 8.3%, respectively. Thus, the productivity for each hospital employee, defined as operations pr. surgeon, outpatient consultations pr. doctor etc. was significantly reduced. A striking finding was that although the number of outpatient consultations increased, the number of new referrals actually went down and the whole increase in activity at the outpatient clinics could be explained by a substantial increase in follow-up consultations. This trend was more evident in the surgical departments, where some departments actually showed a reduction in total outpatient consultations. CONCLUSION: In view of the slow increase in hospital activity in spite of a significant increase in resources, it can be speculated that patient volume might be a limiting factor for hospital activity. The health market (patient population) might not be big enough in relation to the investments in increased production capacity (equipment and manpower).

Efficiency, Organizational↗
PubMed1998

Cost-identification analysis in oral cavity cancer management.

The objectives of this study were to investigate potential relationships between pretreatment patient-mix characteristics, treatment modalities, and costs generated during the pretreatment work-up, treatment, and 1-year follow-up periods for patients with oral cavity cancer (OCC). Another objective was to identify potential areas for cost reduction and improved resource allocation in the management of OCC patients. Using a retrospective cohort of 73 patients with OCC, pretreatment patient-mix characteristics and treatment modalities were evaluated in relation to university-based charges incurred during the pretreatment evaluation, treatment, and 1-year follow-up periods. Simple regression and stepwise multiple regression analyses were used to develop predictive models for cost based on independent variables, including age, AJCC TNM clinical stage, smoking history, American Society of Anesthesiologists (ASA) class, comorbidity as defined by the Kaplan-Feinstein grade and treatment modality. The dependent measurements included all physician, office, and hospital charges incurred at the University of Iowa Hospitals and Clinics during the pretreatment evaluation, treatment, and follow-up periods, as well as the total pretreatment through 1-year follow-up management costs. Independent variables that were identified as being significantly associated with treatment costs included T classification, N classification, TNM stage, unimodality versus multimodality treatment, and the Kaplan-Feinstein comorbidity grade. Age, smoking status, and ASA class were not significantly associated with costs. The majority of the OCC management costs were incurred during the treatment period. The most substantial decreases in management costs for OCC will be realized through measures that allow identification and treatment of disease at an early stage, in which single-modality treatment may effectively be used. Resource allocation for OCC should support the investigation of measures through which the diagnosis and treatment of OCC at the earliest possible stage is facilitated. The presence of comorbid illness is a significant component in the determination of management costs for OCC and should be included in analyses of resource allocation for OCC. The singular diagnosis of OCC encompasses a wide range of patient illness severity, and diagnosis-related reimbursement schemes for OCC treatment should optimally differentiate between early and advanced stage disease.

Aged↗
PubMed2005

[Changes of biomass allocation of Artemisia frigida population in grazing-induced retrogressive communities].

The study showed that under the disturbance of grazing, the biomass of Artemisia frigida leaves, stems, roots and total plant were increased with increasing retrogressive degree, and that of roots was increased more. The biomass of inflorescences and fruits was increased in light retrogressive community while decreased rapidly in mid retrogressive community, and no reproductive model was observed in heavy retrogressive community. With the increase of retrogressive degree, biomass allocation changed. The allocation to roots increased, but that to sexual reproduction decreased, which was badly inhibited in heavy retrogressive community, accompanying with the change of reproduction pattern. As for the dynamics of resource allocation, the resource was prior to allocate to aboveground portion, especially to photosynthesis organ from early to mid growth period, and allocate to sexual reproduction or reserve organ from mid to late growth period, with the increase of retrogressive degree. The alternation of reproductive pattern was the key that A. frigida population resisted grazing and became the established species in heavy retrogressive community. The change pattern of resource allocation made the allocation harmonious between the growth, resistance and reproduction, and was the substantial base that A. frigida population became the constructive species in heavy retrogressive community.

Animal Husbandry↗
PubMed1991

The relationship between skin conductance orienting and the allocation of processing resources.

Information processing models of autonomic orienting suggest that the elicitation of an orienting response is associated with either the call for, or the actual allocation of, limited attentional processing resources. However, Dawson, Filion, and Schell (1989) reported a directional dissociation between elicitation of the skin conductance orienting response and resource allocation, as indexed by reaction time slowing on a secondary task. Although larger skin conductance responses were elicited by a task-relevant stimulus than by a task-irrelevant stimulus, reaction time showed the opposite pattern (i.e., greater slowing to secondary task probes presented shortly following the onset of the task-irrelevant stimulus). In the present report, we describe three experiments which examine the generality of this dissociation effect and test specific hypotheses regarding its nature. Results of the first two experiments revealed that the dissociation effect is observed reliably when the task-relevant and task-irrelevant stimuli consist of left ear and right ear tones or high and low pitched binaural tones, across a range of secondary task probe presentation times. However, the third experiment demonstrated that when task-relevant and task-irrelevant stimuli are presented to different sensory modalities (auditory and visual), orienting and resource allocation are both greater during the task-relevant than the task-irrelevant stimuli, thus eliminating the dissociation effect. These results support the hypothesis that the dissociation effect is due to a switch of attention initiated because of the physical similarity of the task-relevant and task-irrelevant stimuli, and suggest that there is a fundamentally positive relationship between skin conductance orienting and resource allocation under selective attention conditions.

Adult↗
PubMed2005

Choosing the path to bargaining power: an empirical comparison of BATNAs and contributions in negotiation.

Although the negotiations literature identifies a variety of approaches for improving one's power position, the relative benefits of these approaches remain largely unexplored. The empirical study presented in this article begins to address this issue by examining how the size of the bargaining zone affects the relative benefit of an advantage in one's BATNA (i.e., having a better alternative than one's counterpart) versus contribution (i.e., contributing more to the relationship than one's counterpart) for negotiator performance. Results indicate that whereas BATNAs exerted a stronger effect on resource allocations than contributions when the bargaining zone was small, an advantage in contributions exerted a stronger effect on resource allocations than BATNAs when the bargaining zone was large. These findings provide needed insight and supporting evidence for how to alter one's power relationship in negotiation.

Adult↗
PubMed2003

Evaluating health interventions: exploiting the potential.

The importance of the evaluation of health care interventions (EHI) including formal health technology assessment (HTA) cannot be over-emphasised, as its results can inform and improve resource allocation decisions in all parts of the health care system, public and private. At present, fragmented and inefficient resource allocation processes are a universal problem and, as a consequence, patients are deprived of care from which they could benefit. Such outcomes are not only inefficient but also unethical. In this paper we focus on HTA, which emphasises the need to link evidence to policy and practice, but our conclusions can be applied to all types of EHI. There is a need for greater use of economic evidence within HTA. Four principle characteristics of HTA are discussed in this paper: types of knowledge and evaluation, and commissioning and knowledge utilisation. Policy-makers must invest in improving research and receptor capacities for producing and using knowledge, improve quality control, and invest in research into dissemination and implementation mechanisms. The potential of HTA is great, and its use has increased, but it remains largely unexploited in most countries.

Delivery of Health Care↗
PubMed1997

When resources are scarce: the impact of three organizational practices on clinician-managers.

Clinician-managers (CMs) are becoming increasingly responsible for resource allocation decisions, decisions that can spawn ethical issues when resources are scarce. The purpose of the study on which this article is based was to determine which factors would predict CMs' satisfaction with organizational practices that assist them with ethical issues arising from resource allocation decisions.

Analysis of Variance↗
PubMedDate not supplied

What is the value of treating schizophrenia?

OBJECTIVE: Recent generalized cost-effectiveness analyses contrasting schizophrenia with high prevalence mental disorders have noted a need to investigate the mechanisms by which the tensions between equity and efficiency can be reconciled and inform priority setting in resource allocation. This paper explores and illustrates some possible strategies for valuing mental health states, with the broad goal of improving resource allocation decisions. METHOD: Health utility gains derived for current and optimal treatments for schizophrenia, depression and anxiety disorders, potential societal preference weightings, and annual costs per treated case, are used to illustrate the magnitude of the impacts on relative cost-efficiency and societal welfare estimates. These estimates are based on costs per additional quality adjusted life year (QALY) and costs per additional S-QALY (i.e. QALYs adjusted for societal value of health gains) respectively. RESULTS: When broader societal preferences are ignored, current and optimal treatments for depression and anxiety are around 10 times more efficient than those for schizophrenia, but treatments for all three disorders appear to give rise to similar levels of societal welfare when weighting factors reflecting equity concerns are incorporated. CONCLUSIONS: There is manifest inequality in health between individuals with schizophrenia and those with high prevalence mental disorders, even with optimal treatment. Schizophrenia is much more costly to treat but other factors require consideration. Inclusion of societal preferences should lead to more rational decision-making and improved societal welfare. In turn, greater effort needs to be given to the development and validation of appropriate weighting factors reflecting distributive preferences in mental health.

Anxiety Disorders↗
PubMed2006

Purine and folate metabolism as a potential target of sex-specific nutrient allocation in Drosophila and its implication for lifespan-reproduction tradeoff.

The reallocation of metabolic resources is important for survival during periods of limited nutrient intake. This has an influence on diverse physiological processes, including reproduction, repair, and aging. One important aspect of resource allocation is the difference between males and females in response to nutrient stress. We identified several groups of genes that are regulated in a sex-biased manner under complete or protein starvation. These range from expected differences in genes involved in reproductive physiology to those involved in amino acid utilization, sensory perception, immune response, and growth control. A striking difference was observed in purine and the tightly interconnected folate metabolism upon protein starvation. From these results, we conclude that the purine and folate metabolic pathway is a major point of transcriptional regulation during resource allocation and may have relevance for understanding the physiological basis for the observed tradeoff between reproduction and longevity.

Adaptation, Physiological↗
PubMed1999

Ethical issues in the economic assessment of health care technologies.

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare.

Bioethical Issues↗
PubMedDate not supplied

A review of current healthcare funding models.

As healthcare expenses grow, concern about how government and private agencies decide to allocate funds for healthcare resources and services also grows. Decisions for healthcare funding are not made arbitrarily but are based on sound ethical principles and practical considerations. This article is a review of 5 ethically based healthcare funding models discussed in the literature that are currently used to justify funding choices. If healthcare professionals and managers are better informed about the ethical reasoning behind funding choices, they could better determine which resource allocation alternatives to support. But where should we spend our resources? Although healthcare professionals have a duty to advocate for all healthcare recipients to receive a fair share of resources, the author concludes that our greater duty as a profession is to the good of society as a whole. Balancing allocation decisions by considering all of the competing healthcare funding models and the ethical bases for them is suggested rather than to advocate too strongly for favored models.

Choice Behavior↗
PubMed1983

Public money, private control: a case study of hospital financing in Oakland and Berkeley, California.

Government support of public and private hospitals in Oakland and Berkeley, California was investigated. The private hospitals received government subsidies amounting to at least 60 per cent of their total revenues. The dollar amount of the subsidies to private hospitals was four and one-half times greater than government expenditures on the public hospital. In Oakland and Berkeley, as in many cities, public medical services have been reduced while both government health expenditures and private hospital revenues have increased sharply. The private hospitals, although all nominally non-profit, exhibit revenue maximizing behavior which results in socially unjust and medically irrational resource allocation. Funds might be found for public hospitals and clinics, and resources allocated more justly and rationally, if government expenditures in the private sector were brought under greater public scrutiny and control.

California↗
PubMed2001

[Is the portfolio of services a useful instrument for allocating pharmaceutical resources in primary care?].

OBJECTIVE: To find whether in certain primary care teams an association exists between the level of coverage in determined services and expenditure on drugs for pathologies included in these services. DESIGN: Retrospective descriptive study. SETTING: Primary care, INSALUD, Area 1, Huesca. MEASUREMENTS AND MAIN RESULTS: Using the data on coverage of the service portfolio in 1999 and pharmacy expenditure by therapeutic sub-groups during January-October of the same year, the following was analysed:- The service caring for chronic patients: Hypercholesterolaemia and comparison with expenditure in sub-group B04A (lipid-lowerers/ anti-atheroma drugs).- The service caring for chronic patients: Diabetes and comparison with expenditure in sub-groups A10A (insulin) and A10B (oral antidiabetic drugs). Expenditure was expressed as cost adjusted per 100 insured persons, using the INSALUD coefficients for the adjustment (active person coefficient: 0.732; pensioner coefficient: 0.268). The relationship between the two variables was represented graphically by a cloud of dots. Association between them was measured by Pearson's correlation coefficient. No statistically significant correlation was found between coverage and pharmacy expenditure in these sub-groups. Hypercholesterolaemia/lipid-lowerers: Pearson's coefficient = 0.334, 95% CI (-0.115 to 0.669). Diabetes/oral diabetic drugs and insulin: Pearson's coefficient < 0.1. CONCLUSIONS: The differences in coverage of the services analysed bear no direct relationship to pharmacy expenditure. The portfolio of services is not a good method of allocation of pharmaceutical resources.

Health Care Rationing↗