Allocation of resources and identification of issues in determining the cost of nursing services.
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Cost Allocation↗
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[Healthcare rights: an invitation for reflection].
This study focuses on changes and breaks in contemporary society relating to the right to healthcare as a universal value, in conformity with the guidelines provided by multilateral agencies and disseminated particularly since the 1990s. From the genesis of social rights and by tracing the interdependence between social and economic aspects of social citizenship in democratic capitalist countries, the study presents the two paradigms informing the approach to healthcare in the early 21st century: the full citizenship paradigm, according to which the right to healthcare is a universal value, and the paradigm of restricted social citizenship, according to which the right to healthcare is guided by the criterion of efficiency and economic rationalization. These propositions align with the health economy paradigm, which (i) defends focused resource allocation to attenuate poverty conditions, (ii) reduces the role of the state, (iii) recommends resource allocation to healthcare in association with social protection, and (iv) defines the market as the privileged regulator of healthcare actions.
Community Participation↗
DRGs: from development to applications in the Department of Defense.
The evolution of Diagnosis Related Groups (DRGs) is discussed briefly. Use of DRGs for resource allocation in the Veterans Administration is examined. Implications of the use of DRGs for resource allocation and other management functions in the Department of Defense are discussed.
Diagnosis-Related Groups↗
Cost-effectiveness versus cost-utility analysis of interventions for cancer: does adjusting for health-related quality of life really matter?
OBJECTIVE: The US Public Health Service Panel on Cost-Effectiveness has recommended the use of quality-adjusted life-years (QALYs) as the best way to estimate outcomes in a cost-effectiveness analysis. We evaluate the importance of this recommendation by assessing whether adjusting for health-related quality of life affects the ultimate resource allocation decision implied by the cost-effectiveness ratio for interventions aimed at cancer prevention and control. METHODS: We identified 110 interventions in 39 articles for which both cost/life-year and cost/QALY were reported. Interventions were forms of prevention, early detection, or treatment of cancer. We calculated a Spearman correlation to assess the ordinal relationship between cost/life-year and cost/QALY. In addition, we employed various decision thresholds to assess whether the use of cost/life-year would yield different resource allocation decisions than the use of cost/QALY. RESULTS: The correlation between cost/life-year and cost/QALY is 0.96 (P <.0001). Assuming a US dollars 50000 decision threshold, adjustment for quality of life would affect the implied choice in 5% of cases. With a US dollars 400000 threshold, adjustment for quality of life would affect choice for 2% of interventions. CONCLUSIONS: For interventions aimed at cancer, the outcome measures of cost/life-year and cost/QALY are highly correlated with one another. Although adjusting for quality of life can make an important difference in the evaluation of alternative approaches to cancer prevention and control, it often does not.
Cost-Benefit Analysis↗
Allocation of resources for ambulatory care -a staffing model for outpatient clinics.
The enormous commitment of resources to ambulatory health care services requires that flexible and easily implementable management techniques be developed to improve the allocation of health manpower and funds. This article develops a feasible model for staffing outpatient clinics and thereby potentially provides an important analytical tool for allocating and monitoring the utilization of the most critical and expensive of ambulatory care resources-professional and nonprofessional clinic personnel. The model is simplistic, extremely flexible, and can be applied to many modes of delivering ambulatory care-from HMOs to traditional hospital outpatient clinics. To employ the model, certain decision variables must be specified so that the model can produce a least-cost staffing configuration to meet the demand for service in accordance with the desired mode and intensity of care. The key decision varables that require input from administrators and medical personnel include standards for physician-patient contact time, a desired ratio of staff time actually spent treating patients to total paid staff time, and the desired mix of various staff categories to achieve program objectives. Specific benefits of using the model include determining staffing for new, expanded, or existing outpatient clinics, determining budget requirements for such staffing needs, and providing quantitative productivity and utilization objectives and measurements.
Ambulatory Care↗
Resource reallocation in an emergency medical service system using computer simulation.
Emergency medical service (EMS) policy makers must seek to achieve maximum effectiveness with finite resources. This research establishes an EMS computer simulation model using eM-Plant software. The simulation model is based on Taipei city's EMS system with input data from prehospital care records from December 2000; it manipulates resource allocation levels and rates of idle errands. Presently, EMS ambulance utilization is about 8.78%. On average, 20.89 minutes are required to transport a patient to the hospital. Computer simulations showed that reducing the number of ambulances to one at each of the 36 response units increases the utilization rate to 15.47% but does not compromise the current service quality level. Thus, ambulance utilization improves, times of patients waiting for pre-hospital care and arrival at hospitals are only slightly affected, and considerable cost savings result. This study provides a research methodology and suggests specific policy directions for resource allocation in EMS. Limiting the number of ambulances to one per response unit reduces costs, increases efficiency, and yet maintains the same operational pattern of medical service.
Ambulances↗
Quality-adjusted life-years. Ethical implications for physicians and policymakers.
Quality-adjusted life-years have been used in economic analyses as a measure of health outcomes, one that reflects both lives saved and patients' valuations of quality of life in alternative health states. The concept of "cost per quality-adjusted life year" as a guideline for resource allocation is founded on six ethical assumptions: quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims. Quality-adjusted life-years signal two shifts in the locus of control and the nature of the clinical encounter: first, formal expressions of community preferences and societal usefulness would counterbalance patient autonomy, and second, formal tools of resource allocation and applied decision analysis would counterbalance the use of clinical judgment. These shifts reflect and reinforce a new financial ethos in medical decision making. Presently using quality-adjusted life-years for health policy decisions is problematic and speculative; using quality-adjusted life-years at the bedside is dangerous.
Cost-Benefit Analysis↗
The role of decision-analytic models in the prevention, diagnosis and treatment of coronary heart disease.
BACKGROUND: The rapidly expanding number and scope of health technologies used in the prevention, diagnosis, and treatment of coronary heart disease present physicians and policy makers with complex decisions that must be made even under uncertainty about the risks and benefits of these procedures. A physician must determine which procedures offer the best trade-off between potential harm and benefit, and yield the maximum expected health benefit for the patient. In addition, the cost-effectiveness of alternative choices must be considered to optimize resource allocations from a societal perspective, further complicating the decision making process. METHODS: Decision analysis is the application of explicit and quantitative methods to analyze decisions under conditions of uncertainty. Briefly, the basic concepts of decision analysis and cost-effectiveness analysis are described. Three examples of decision-analytic models for the prevention, diagnosis, and treatment of coronary heart disease are discussed to demonstrate situations in which decision analysis may be helpful, and to introduce different methodological approaches. CONCLUSION: Decision analysis may aid clinical decisions affecting individual patients as well as inform clinical policy decisions and decisions regarding national health policy. However, this method is not a complete procedure for determining resource allocation decisions in health care, because it cannot incorporate all the values relevant to such decisions.
Adult↗
Birth weight-specific mortality for extremely low birth weight infants vanishes by four days of life: epidemiology and ethics in the neonatal intensive care unit.
BACKGROUND: The persistent differences between those who question the appropriateness of aggressive resuscitative measures for many extremely low birth weight (ELBW) infants (birth weight < 1001 g) and those who generally initiate such treatment has been a source of ongoing tension for physicians, parents, judges, and policymakers. We believe that much of this tension may be a result of the way the issue is framed. We began this study with the intuition that although many ELBW infants die, most succumb quickly. Were this true, discussions that considered only survival rates might miss the point. A more relevant statistic might be the degree to which interventions prolong dying, extend suffering, or use resources for infants who will eventually die. METHODS: We determined the survival and nonsurvival for 429 ELBW infants admitted to our neonatal intensive care unit (NICU) for 3 years. We noted particularly the relationship between birth weight, illness severity (fraction of inspired oxygen [Fio2] requirement for infants requiring mechanical ventilation), and the time course of mortality for nonsurvivors. We next calculated a resource utilization index (NICU bed days occupied by survivors and nonsurvivors) for each patient and for the population as a whole. Finally, we determined how NICU resources were distributed among infants who eventually died and those who survived. RESULTS: Of the 429 ELBW infants alive on day of life (DOL) 1,202 (47%) survived to be discharged. on DOL 1, both birth weight and illness severity independently predicted likelihood of survival. Approximately 80% of ELBW deaths occurred in the first 3 days of life-- consequently, once an infant had survived to DOL 4, the likelihood of survival was dramatically enhanced (81% for the 249 patients alive on DOL 4). In addition, although survival for DOL 4 infants continued to depend on illness severity, survival no longer depended on birth weight. These observations on DOL 4 were confirmed in the subpopulation of 212 infants whose birth weight was < 750 g. Overall, although 53% of ELBW babies admitted died, only approximately 13% of all NICU bed-days (a proxy for resource allocation) were devoted to infants who did not survive. This figure did not vary as a function of birth weight. CONCLUSION: Generally, when we talk of survival rates to parents, ethics committees, or policy makers, we base our predictions largely on birth weight. The data presented here suggest that predictions should be corrected by including DOL and that, when this is done, the prognostic value of birth weight rapidly diminishes. In addition, birth weight-specific mortality and day of death for nonsurvivors correlated inversely; that is more of the smaller infants died, but the doomed ones died more quickly. Consequently, medical resources allocated to nonsurvivors remained low, and independent of birth weight. This formulation lends weight both to the reasonableness of physicians in offering NICU care to ELBW infants, with unlikely prospects for survival, and of parents and surrogate decision-makers in requesting/ assenting to it.
Bed Occupancy↗
How stable are people's preferences for giving priority to severely ill patients?
BACKGROUND: Previous studies have suggested that people favor allocating resources to severely ill patients even when they benefit less from treatment than do less severely ill patients. This study explores the stability of people's preferences for treating severely ill patients. METHODS: This study surveyed prospective jurors in Philadelphia and asked them to decide how they would allocate scarce health care resources between a severely ill group of patients who would improve a little with treatment and moderately ill patients who would improve considerably with treatment. Subjects were randomized to receive one of six questionnaire versions, which altered the wording of the scenarios and altered whether subjects were given an explicit option of dividing resources evenly between the two groups of patients. RESULTS: Four hundred and seventy nine subjects completed surveys. The preference subjects placed on allocating resources to severely ill patients depended on relatively minor wording changes in the scenarios. In addition, when given the explicit option of dividing resources evenly between the two groups of patients, the majority of subjects chose to do so. CONCLUSION: People's preferences for allocating resources to severely ill patients can be significantly decreased by subtle wording changes in scenarios. However, this study adds to evidence suggesting that many people place priority on allocating resources to severely ill patients, even when they would benefit less from treatment than others.
Adult↗
The turmoil of aboriginal enumeration: mobility and service population analysis in a central Australian community.
This paper documents Aboriginal population change and mobility over time in a remote community in central Australia. The movement of population has implications for service delivery and resource allocation. Aboriginal population in the region is characterised by high mobility. We conducted four population surveys in a selected remote community over a 12 month period and categorised individuals into four mutually exclusive groups: residents, dual residents, visitors and absent residents. Based on these categories we developed two population classifications: actual and potential service populations. The potential service population was consistently higher than the Australian Bureau of Statistics (ABS) census figure. We question the use of ABS census estimates as appropriate population figures for determining resource allocation to remote communities. We quantify inter- and intra-community mobility. When the potential population is used as denominator, 35% of the population of this community was classified as inter-community mobile. Given this level of mobility we argue that: (1) Resources should be allocated to compensate health services for the additional time and resource requirements to deal with the high level of population mobility. (2) Health programs such as STD control, trachoma, scabies and other communicable diseases common in Central Australia should be coordinated and delivered as regional programs often crossing State/Territory borders.
Australia↗
Social rates of return to investment in skills assessment and residency training of international medical graduates in Alberta.
Governments and physician organizations in Canada have identified current and anticipated future shortages of physicians. The creation of opportunities for licensure for the sizeable population of unlicensed international medical graduates (IMG) residing in Canada can alleviate some of the shortage of medical manpower. We examine whether expenditures on IMG skills assessment, training and licensing are a socially desirable use of resources. We estimate the financial rate of return to Alberta taxpayers from resources allocated to the Alberta International Medical Graduate (AIMG) program, started in 2001. Our estimates show that resources allocated to providing skills assessment and residency training opportunities for IMGs that lead to licensing as a Canadian physician generate real annual rates of return of 9-13%.
Adult↗
The utility of DALYs for public health policy and research: a reply.
The WHO Advisory Committee on Health Research (ACHR), through its DALY Review Group, has recently criticized the use of disability-adjusted life years (DALYs). To suggest that the use of DALYs should be discouraged as an aid in health resource allocation may, however, be premature, since it enhances informed debate on the social values that influence resource allocation, identifies health problems that may be neglected, and points to the strengths and weaknesses of existing health information systems.
Persons with Disabilities↗
Making access to health care more equal: the role of general medical services.
The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP's aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.
Family Practice↗
Using practice guidelines to allocate medical technologies. An ethics framework.
Clinical practice guidelines are expanding their scope of authority from clinical decision making to collective policy making, and promise to gain ground as resource allocation tools in coming years. A close examination of how guidelines approach patient selection criteria offers insight into their ethical implications when used as resource allocation or rationing instruments. The purposes of this paper are: a) to examine the structure of allocative reasoning found in clinical guidelines; b) to identify the ethical principles implied and compare how guidelines enact these principles with how explicit systems-level rationing exercises and health policy analyses have approached them; and c) to offer some preliminary suggestions for how these ethical issues might be addressed in the process of guideline development. The resulting framework can be used by guideline developers and users to understand and address some of the ethical issues raised by guidelines for the use of scarce technologies.
Biomedical Technology↗
[Allocation of economic resources in medicine. The example of "peak medicine"].
The application of economic rules of allocation to tragic situations, which are often given in the health care system, is confronted with the problem, that economic decision rules normally follow an act-consequential ethic while medical decision rules have a strong affinity to a result-consequential ethic. The limited willing-ness-to-pay for health care leads to the necessity to use economic rules of resource allocation both on a global and on a personal level. But differences in the structure of the decision call for different rules of resource allocation. On a global level the allocation rule should be dominated by economic efficiency, while on a personal level the allocation rule should be guided by ideas of equity and fairness.
Austria↗
Measuring the value of pharmacogenomics.
Pharmacogenetics and pharmacogenomics offer the potential of developing DNA-based tests to help maximize drug efficacy and enhance drug safety. Major scientific advances in this field have brought us to the point where such tests are poised to enter more widespread clinical use. However, many questions have been raised about whether such tests will be of significant value, and how to assess this. Here, we review the application of economics-based resource-allocation frameworks to assess the value of pharmacogenomics, and the findings so far. We then develop a resource-allocation framework for assessing the potential value of pharmacogenomic testing from a population perspective, and apply this framework to the example of testing for variant alleles of CYP2D6, an important drug-metabolizing enzyme. This review provides a framework for analysing the value of pharmacogenomic interventions, and suggests where further research and development could be most beneficial.
Humans↗
Ethics and professionalism: what does a resident need to learn?
Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.
Adult↗