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PubMed1999

Measuring progress towards a primary care-led NHS.

BACKGROUND: The push towards a 'primary care-led' National Health Service (NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practitioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent Scottish Health Service White Paper and its English counterpart. AIM: To consider three questions in relation to this policy goal. First, does the evidence base support the changes? Secondly, what is the scale of the changes that have occurred? Thirdly, what are the barriers to the development of a primary care-led NHS? METHOD: Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary care. Total NHS revenue expenditure for the 15 Scottish health boards was grouped into four blocks or 'programmes': primary care, secondary care, community services, and a residual. The study period was 1991/2 to 1995/6. Expenditure data were supplied by the Scottish Office. RESULTS: Ambiguity of definitions and the absence of good data cause methodological difficulties in evaluating the scale and the appropriateness of the shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation between care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth money rather than a 'shift' from secondary care. In addition, the impact of GP-led commissioning is variable but limited. CONCLUSION: General practitioners' (GPs') attitudes to the policy suggest that progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the shift on the part of GPs, suggest that this is a policy objective that may not be achieved.

Delivery of Health Care↗
PubMed1998

Resource implications for oral care of patients with HIV.

OBJECTIVES: The aim was to investigate the attitudes of people with HIV infection towards their own dental care provision and the possible implications for future resource allocation. DESIGN: Sixty-nine HIV positive subjects attending support groups in London were interviewed. Past and current dental visiting behaviour, problems encountered in obtaining dental care and preferred site of delivery for dental care were investigated. RESULTS: Showed that a majority (74%) changed dentist or stopped attending following diagnosis with HIV, either due to fear of or actual refusal of treatment, a desire to attend a more sympathetic dentist or to attend a specialist clinic. Forty-five per cent withheld information about their status. Subjects expressed a desire to receive regular dental care and had definite preferences as to the site of delivery, 45% preferring general practice, 48% specialist clinics. CONCLUSIONS: Future resource allocation should be used for continued support and education of general dental practitioners willing to treat HIV positive patients, and for accessible specialist referral centres. Hospital clinics could also provide regular routine care, especially in areas of large HIV populations. An improved awareness of and access to community dental clinics appears to be needed, with efforts focused on achieving an informed and educated patient population through education programmes.

Adolescent↗
PubMed2004

Antagonistic pleiotropy for life-history traits at the gene expression level.

Life-history trade-offs prevent different components of fitness from being maximized simultaneously. Although the existence of trade-offs has been clearly demonstrated, the 'classical' mechanism of adaptive resource allocation that should underlie them has recently received criticism. In this study, we explore the molecular mechanisms of life-history trade-offs by applying a quantitative genomic approach. Analysis of global gene expression in Drosophila melanogaster revealed 34 genes whose expression coincided with the genetic trade-off between larval survival and adult size. The joint expression of these candidate 'trade-off' genes explained 86.3% of the trade-off. Fourteen of these genes have known functions which suggest that the larval survival-adult size trade-off could be the result of resource allocation at the organismal level, but at the level of cellular metabolism the trade-off would reduce to a shift between energy metabolism versus protein biosynthesis, regulated by the RAS signalling pathway.

Adaptation, Physiological↗
PubMed1995

A critical review of health-related economic evaluations in Australia: implications for health policy.

In Australia, as in many other countries, economic evaluation is increasingly seen by health care policy makers as a useful aid to priority setting and resource allocation. In Australia, economic evaluation is now a requirement for new drugs to be listed on the Pharmaceutical Benefits Scheme which provides a government subsidy on the price of listed drugs for purchasers. Yet, despite recognition of the importance of economic evaluation by policy makers, there is a paucity of published evaluations in Australia. We reviewed all of the 33 health-related economic evaluations conducted in Australia and subsequently published since 1978. This study assesses how well informed decision makers might be if they used the results and conclusions of published economic evaluations as an aid to resource allocation. The review highlights several issues: (i) it is difficult to interpret the conclusions or assess the generalisability of individual papers without information on the context of the original study; (ii) the choice of comparator(s) was often unexplained and most papers did not employ marginal analysis; (iii) in the absence of marginal analysis, the comparability of cost-effectiveness ratios in league tables must be questioned as well as the completeness (were all the relevant alternatives included?) of studies; and (iv) the quality of effectiveness evidence varies enormously, with some authors content to use the best available evidence (even if it is of poor quality). The development of standards for economic evaluation methods might ensure a more consistent and scientific approach to evaluative work, but they cannot guarantee it. A more concerted effort to disseminate the principles and methods of economic evaluation to policy makers and non-economist evaluators might be a more important precursor to improving the credibility and usefulness of economic evaluations in priority setting.

Australia↗
PubMed2003

A synthetic review of the theory of gynodioecy.

Cytoplasmic male sterility alleles (CMS) and corresponding nuclear restorer alleles (R) determine gender expression in gynodioecious populations. In this article, we combine cytonuclear epistasis theory, multilevel selection theory, and resource allocation theory to partition the many selective forces acting in gynodioecious species. This description of selective forces reveals that the notion that genomic conflict leads to the spread of restorers is erroneous. By elucidating the effect of each selective force alone and in combination with the others, our approach shows why change in a single parameter, such as the degree of restorer dominance or the cost of restoration, can result in a myriad of opposing selective effects, making it difficult to test theoretical predictions in experimental systems. In particular, our approach allows us to identify the harmonic mean resource allocation between pollen and ovules and the attendant Fisherian selection as playing a critical role in the evolution of the restorer allele and gender polymorphism. We use this conceptual framework to propose empirical methods that emphasize the role of Fisherian selection acting in gynodioecious populations. Because our approach increases the number and specificity of theoretical predictions, we argue that it provides a better framework for empirical testing.

Cytoplasm↗
PubMed2000

Floral dimorphism, pollination, and self-fertilization in gynodioecious GERANIUM RICHARDSONII (Geraniaceae).

The selective maintenance of gynodioecy depends on the relative fitness of the male-sterile (female) and hermaphroditic morphs. Females may compensate for their loss of male fitness by reallocating resources from male function (pollen production and pollinator attraction) to female function (seeds and fruits), thus increasing seed production. Females may also benefit from their inability to self-fertilize if selfing and inbreeding depression reduce seed quality in hermaphrodites. We investigated how differences in floral resource allocation (flower size) between female and hermaphroditic plants affect two measures of female reproductive success, pollinator visitation and pollen receipt, in gynodioecious populations of Geranium richardsonii in Colorado. Using emasculation treatments in natural populations, we further examined whether selfing by autogamy and geitonogamy comprises a significant proportion of pollen receipt by hermaphrodites. Flowers of female plants are significantly smaller than those of hermaphrodites. The reduction in allocation to pollinator-attracting structures (petals) is correlated with a significant reduction in pollinator visitation to female flowers in artificial arrays. The reduction in attractiveness is further manifested in significantly less pollen being deposited on the stigmas of female flowers in natural populations. Autogamy is rare in these protandrous flowers, and geitonogamy accounts for most of the difference in pollen receipt between hermaphrodites and females. Female success at receiving pollen was negatively frequency dependent on the relative frequency of females in populations. Thus, two of the prerequisites for the maintenance of females in gynodioecious populations, differences in resource allocation between floral morphs and high selfing rates in hermaphrodites, occur in G. richardsonii.

Journal Article↗
PubMed1985

Processing of stimulus properties: evidence for dual-task integrality.

The conditions under which dual-task integrality can be fostered were assessed in a study in which we manipulated four factors likely to influence the integrality between tasks: intertask redundancy, the spatial proximity of primary and secondary task displays, the degree to which primary and secondary task displays constitute a single object, and the resource demands of the two tasks. The resource allocation policy is inferred from changes in the amplitude of the P300 component of the event-related brain potential. Twelve subjects participated in three experimental sessions in which they performed both single and dual tasks. The primary task was a pursuit step tracking task. The secondary tasks required subjects to discriminate between different intensities or different spatial positions of a stimulus. Task pairs that required the processing of different properties of the same object resulted in better performance than task pairs that required the processing of different objects. Furthermore, these same object task pairs led to a positive relation between primary task difficulty and the resources allocated to secondary task stimuli. Intertask redundancy and the physical proximity of task displays produced similar effects of reduced magnitude.

Adolescent↗
PubMed2006

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↗
PubMed2000

Priorities in care and services for elderly people: a path without guidelines?

The growing gap between demands and resources is putting immense pressure on all government spending in Sweden. The gap is especially apparent in care and services for elderly people in light of the rapid aging of the population. The article considers the decisions and priorities concerning resource allocation in the welfare sector in general and in elderly care in particular. The aim is to describe the political and administrative setting and to provide a conceptual structure that outlines the nature of the problem. Various levels of decision making are identified and discussed in the context of political accountability. Current transitions in elderly care are described with respect to service provision, marketisation, coverage rates, and eligibility standards. Basic principles of distribution are highlighted in order to clarify some central concepts of efficiency and justice, and a number of strategies for actual prioritising are identified. The article concludes with an endorsement of more conscious decisions in resource allocation. Existing knowledge and information concerning the effects of various strategies must be utilised, and the values and assumptions used for setting priorities must be made explicit.

Aged↗
PubMedDate not supplied

Challenges of major incident management when excess resources are allocated: experiences from a mass casualty incident after roof collapse of a military command center.

During a military exercise in northern Norway in March 2000, the snow-laden roof of a command center collapsed with 76 persons inside. Twenty-five persons were entrapped and/or buried under snow masses. There were three deaths. Seven patients had serious injuries, three had moderate injuries, and 16 had minor injuries. A military Convalescence Camp that had been set up in a Sports Hall 125 meters from the scene was reorganized as a causality clearing station. Officers from the Convalescence Camp initially organized search and rescue. In all, 417 persons took part in the rescue work with 36 ambulances, 17 helicopters, three ambulance airplanes and one transport plane available. Two ambulances, five helicopters and one transport aircraft were used. Four patients were evacuated to a civilian hospital and six to a field hospital. The stretcher and treatment teams initially could have been more effectively organized. As resources were ample, this was a mass casualty, not a disaster. Firm incident command prevented the influx of excess resources.

Cold Climate↗
PubMed1993

The economic costs of asthma: a review and conceptual model.

There is a growing international concern about increasing asthma morbidity. While much is known about asthma morbidity, there are few available data on the economic burden of this condition, particularly in underdeveloped countries. In the absence of data on social costs, it is not possible to develop rational approaches to policies regarding resource allocation to reduce morbidity. The purpose of this article is to provide a review of the available literature on the social costs of illness for asthma. In light of this literature, we propose a conceptual model that links asthma morbidity to the social opportunity costs of the disease. We then delineate a framework, based on the proposed model, that can be used to conceptualise and evaluate the relative impact of alternative asthma intervention strategies. Based upon proposed analyses using this model, we believe that it would be possible to compare how various intervention strategies are likely to affect asthma costs and morbidity, thus providing a means for a more rational approach to healthcare policies regarding societal resource allocation for asthma.

Asthma↗
PubMed1991

Migration, cash cropping and subsistence agriculture: relationships to household food expenditures in rural Mexico.

The relationship between income and food expenditure patterns is influenced by a number of factors, including personal tastes, source and frequency of income, male/female control over income, home food production, and other demographic factors. In this study, the relationship of household resource allocation to each of the following is examined: (1) source of income (i.e. wage labor, cash cropping, migrant remittances, and other private sources); (2) women's contribution to income; and (3) subsistence production level. The overall study design involved a cross-sectional survey of 178 households in three rural Mexican communities on two occasions spanning both agricultural seasons. On each occasion, data were collected on the following: (1) income by source and by earner; (2) migrant remittances; (3) gifts and loans; (4) subsistence and cash crop production, expenses, and earnings; (5) major nonfood purchases; (6) household composition; and (7) household food use (during the previous week). Stepwise multiple regression was used to determine the factors associated with the percentage of income allocated to food (PFX) and the percentage of the food budget allocated to (1) maize, beans, and chile (TRAD); (2) meat, milk, and fruit (LUX); and (3) bread, pasta, and snack foods (PROC). All regressions were run controlling for income. The proportion of income from migrant remittances was negatively associated with PFX (winter). Subsistence score was positively related to PFX (summer). Migrant remittances (winter) and subsistence score (both seasons) were negatively associated with TRAD. Subsistence score was positively related to LUX (both seasons). Father's absence (both seasons), store ownership (winter), and private source of income (summer) were all positively linked to PROC. Mother's contribution to total income and cash cropping income were not significantly related to any of the dependent variables. The findings support the idea that resource allocation patterns are influenced not only by income level but also by the household economic strategies through which income is generated.

Agriculture↗
PubMed1996

Efficiency measurement and the operationalization of hospital production.

OBJECTIVE: To discuss the usefulness of efficiency measures as instruments of monitoring and resource allocation by analyzing their invariance to changes in the operationalization of hospital production. STUDY SETTING: Norwegian hospitals over the three-year period 1989-1991. STUDY DESIGN: Efficiency is measured using Data Envelopment Analysis (DEA). The distribution of efficiency and the ranking of hospitals is compared across models using various distribution-free tests. DATA COLLECTION: Input and output data are collected by the Norwegian Central Bureau of Statistics. PRINCIPAL FINDINGS: The distribution of efficiency is found to be unaffected by changes in the specification of hospital output. Both the ranking of hospitals and the scale properties of the technology, however, are found to depend on the choice of output specification. CONCLUSION: Extreme care should be taken before resource allocation is based on DEA-type efficiency measures alone. Both the identification of efficient and inefficient hospitals and the cardinal measure of inefficiency will depend on the specification of output. Since the scale properties of the technology also vary with the specification of output, the search for an optimal hospital size may be futile.

Efficiency, Organizational↗
PubMed2000

The cost of integrating hepatitis B virus vaccine into national immunization programmes: a case study from Addis Ababa.

National programmes of hepatitis B virus (HBV) vaccination are recommended by the World Health Organization for all countries. Countries suffering the highest burden of HBV disease are those most needy of universal vaccination, but are frequently of very low income and resources for health care are scarce. The introduction of HBV vaccination would inevitably stretch these resources further even with support of donor agencies. Thus an assessment of the cost-effectiveness of HBV vaccination is desirable to assist in decision making about resource allocation. We describe here a method for estimating the additional costs of introducing HBV vaccination into the Expanded Programme on Immunization (EPI) at a national level. Of fundamental importance is that this method enables costs to be assessed prior to the introduction of vaccination. We illustrate the method using a study carried out at the sub-national level, in the city of Addis Ababa, Ethiopia, but which can be expanded countrywide. The method, in brief, involved the use of a number of questionnaires which could be used to estimate the costs associated with the EPI programme from a large sample of the static clinics as well as from central sources. Since unit costs were collected along with the quantities of resources used and estimates of the capacity used for certain facilities (such as refrigerators), the additional cost of introducing HBV vaccine could be estimated largely by extrapolation of the resources used in vaccinating against diphtheria/pertussis/tetanus vaccine (which, similar to HBV vaccine, requires three doses). The estimation of costs is only part of the information required to make decisions on resource allocation, and should be used in association with measures of the burden of disease due to the infection in the community and effectiveness of the control programme at reducing this burden. The prediction of the latter, based upon a sound epidemiological understanding of the infection, is the subject of a forthcoming paper.

Cost Allocation↗
PubMed2000

Building uncertainty into cost-effectiveness rankings: portfolio risk-return tradeoffs and implications for decision rules.

BACKGROUND: Current principles of cost-effectiveness analysis emphasize the rank ordering of programs by expected economic return (eg, quality-adjusted life-years gained per dollar expended). This criterion ignores the variance associated with the cost-effectiveness of a program, yet variance is a common measure of risk when financial investment options are appraised. Variation in health care program return is likely to be a criterion of program selection for health care managers with fixed budgets and outcome performance targets. METHODS: Characterizing health care resource allocation as a risky investment problem, we show how concepts of portfolio analysis from financial economics can be adopted as a conceptual framework for presenting cost-effectiveness data from multiple programs as mean-variance data. RESULTS: Two specific propositions emerge: (1) the current convention of ranking programs by expected return is a special case of the portfolio selection problem in which the decision maker is assumed to be indifferent to risk, and (2) for risk-averse decision makers, the degree of joint risk or covariation in cost-effectiveness between programs will create incentives to diversify an investment portfolio. CONCLUSIONS: The conventional normative assumption of risk neutrality for social-level public investment decisions does not apply to a large number of health care resource allocation decisions in which health care managers seek to maximize returns subject to budget constraints and performance targets. Portfolio theory offers a useful framework for studying mean-variance tradeoffs in cost-effectiveness and offers some positive predictions (and explanations) of actual decision making in the health care sector.

Cost-Benefit Analysis↗
PubMed1997

QALYs and mental health care.

Quality-adjusted life year measures (QALYs) have been fervently debated by researchers and decision makers concerned with resource allocation in the health care sector. They have been heralded as important aids to planning and priority setting, but also criticised on technical and ethical grounds. This paper examines these arguments with special reference to mental health care, the intention being to highlight the strengths and shortcomings of QALYs in this context. Issues pertinent to the application of QALYs in health care evaluation more generally are also reviewed. Whilst the rationale and underlying principles of the utility measurement approach are sound, the generic QALY as it is currently constructed represents an insensitive measure of the outcomes of mental health care. In the event of an increasingly QALY-driven priority-setting environment, however, abandonment of QALYs runs the risk of inappropriately marginalising people with mental illnesses in the resource allocation process. This opens up the possibility of developing a mental-health specific measure of utility that, in combination with cost data, would provide useful and appropriate summary information across treatments and programmes of mental health care.

Cost-Benefit Analysis↗
PubMed2003

Justice within social dilemmas.

The defining feature of social dilemma situations is the inherent conflict faced by those involved: should one act in his or her own individual best interest or sacrifice a measure of one's personal payoff to help maximize the joint payoff of the group as a whole? In such dilemmas, those making individualistic and defecting choices are always at a competitive advantage relative to those who choose to cooperate. One seemingly inevitable consequence of the resulting resource allocation asymmetry is that it must challenge and threaten the cooperator's sense of fairness and justice, and it is the reaction of those caught in social dilemmas to this injustice and unfairness that is the focus of this article. We examine how justice processes-distributive justice, procedural justice, restorative justice, and retributive justice-operate in social dilemmas. Within this examination, we consider ideas from classic and contemporary conceptual analyses of justice to provide a broader context within which to understand social dilemmas and the roles that justice plays as people strive to ensure fair outcomes for themselves and for others. We conclude with the proposal of a 4-stage, sequential model of justice in social dilemmas that posits groups move between the types of justice concerns when unfair and unsatisfactory outcomes (e.g., inequitable resource allocations, violations of agreed-on allocation rules, intentional and egregious exploitation of the group) cause members to "recognize the necessity" for change to ensure fair and just outcomes for all.

Conflict, Psychological↗
PubMed2004

Quantitative trait loci affecting starvation resistance in Drosophila melanogaster.

The ability to withstand periods of scarce food resources is an important fitness trait. Starvation resistance is a quantitative trait controlled by multiple interacting genes and exhibits considerable genetic variation in natural populations. This genetic variation could be maintained in the face of strong selection due to a trade-off in resource allocation between reproductive activity and individual survival. Knowledge of the genes affecting starvation tolerance and the subset of genes that affect variation in starvation resistance in natural populations would enable us to evaluate this hypothesis from a quantitative genetic perspective. We screened 933 co-isogenic P-element insertion lines to identify candidate genes affecting starvation tolerance. A total of 383 P-element insertions induced highly significant and often sex-specific mutational variance in starvation resistance. We also used deficiency complementation mapping followed by complementation to mutations to identify 12 genes contributing to variation in starvation resistance between two wild-type strains. The genes we identified are involved in oogenesis, metabolism, and feeding behaviors, indicating a possible link to reproduction and survival. However, we also found genes with cell fate specification and cell proliferation phenotypes, which implies that resource allocation during development and at the cellular level may also influence the phenotypic response to starvation.

Analysis of Variance↗