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PubMed1999

Priority-setting and rationing in German health care.

While the framework for the German statutory health insurance system is determined at the national level and the states have a significant influence on the provision of hospital care and public health services, most decisions on the actual delivery of curative health care services are made through joint negotiations between the associations of the physicians and the sickness funds at various levels. Decisions with effects on priority-setting include the determination of the benefit package and financial regulations. The actual provision of care is further regulated through guidelines, e. g. about the prescription of pharmaceuticals. Financial regulations include both the setting of budget limits and the determination of relative point values which affect remuneration and serve as incentives to provide certain services (or not). A survey of 2000 citizens reveals, however, that the majority of the public favours unlimited funding for health services and that treatment decisions should be made by doctors. Limiting the benefits catalogue to a core of essential services is rejected as well as priorities based on age. Separately interviewed experts expect further limitations of therapeutic freedom, however. Germany seems to be just at the beginning of a public debate on priority-setting and rationing in health care.

Ambulatory Care↗
PubMed1997

"Ruling in" and "ruling out": two approaches to the micro-rationing of health care.

Much of the implicit rationing said to characterise British health care occurs as doctors decide what resources to allocate to individual patients. This paper examines this process using data from case studies of selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. The analysis focuses on cardiac catheterisation conferences in which cardiologists present surgical candidates to a cardiac surgeon, and neuro-rehabilitation admissions conferences in which a multidisciplinary team assess the suitability of head injury and stroke patients referred by hospital doctors. For much of the time participants in both settings discuss patients within a clinical discourse that relies on technical assessments of coronary anatomy, ADL scores and the like. However, there are many examples where the discourse "frame" shifts to address patient characteristics of a social or moral nature. Information of this kind tends to be deployed in two ways: it can be used to signal the patient's unsuitability, usually on the basis that past behaviour implies poor prognosis ("ruling out"), or it can be used to suggest that a patient is especially deserving of help ("ruling in"). Analysis of the data suggests that "ruling out" is more salient within the cardiac catheterisation conferences, and "ruling in" within the neuro-rehabilitation admissions conferences. The authors suggest that this reflects differences in the work organisation of the two specialties, including the division of labour, the organisation of waiting lists as a queue or a pool, and the putative significance of patient agency in the genesis of disease and recovery.

Adult↗
PubMed1998

Age rationing for renal transplantation? The role of age in decisions regarding scarce life extending medical resources.

The use of age as a selection criterion for scarce life extending medical resources is justified by some theorists and rejected by others. Qualitative research was conducted into age rationing in daily medical practice. Observations were made at two renal transplantation centres and people professionally involved in decision making about transplantation were interviewed. Age appeared to be an important factor in indication decisions concerning individual patients, because it is associated in several ways with both the risks and benefits of transplantation that are weighed against each other. This happens apart from scarcity of donor organs. However, age also appeared to be used as a selection criterion, though apparently to a slight degree. This happens in a covert, implicit way. This is possible because all the aspects of age that are important in indication decisions regarding individual patients may also be used as comparative selection criteria.

Adult↗
PubMed2002

Elderly people's accounts of home care rationing: missing voices in long-term care policy debates.

Fundamental shifts in state intervention in recent years have resulted in steady curtailment in public provision of community and social care. A longitudinal study of elderly women receiving home care in Ontario explored the reverberations of these shifts in the texture of frail elderly people's lives. Three distinct accounts of negotiating unstable and rationed home care were discernible. "Taking charge" was an active account of women successfully impressing their particular needs and identities on home care provision. "Pushed over the edge" was a vulnerable account of insufficient and depersonalized care in which participants felt themselves practically and emotionally out of control. In "Restraining expectations", women adjusted silently to the shortcomings of home care, stoically making themselves smaller as they found their previous orbits and identities unsupported. Home care's front line emerged as a complex site of struggle for identity and agency--a struggle in which elderly people engage with inventiveness and determination but also with dwindling support, few witnesses and in mounting isolation.

Aged↗
PubMed1999

QALYs and the integration of claims in health-care rationing.

The paper argues against the polarization of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximization as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualization of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. We identify the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalized within the mathematical framework provided by non-linear programming.

Attitude to Health↗
PubMed1993

An appraisal of rational-emotive therapy.

Albert Ellis's rational-emotive therapy (RET) is scrutinized on several conceptual and empirical grounds, including its reliance on constructive assessment and its ethical stance. Its professional impact thus far exceeds its scientific status. Opinion varies on how even to define irrational beliefs; 1 consequence is problems in assessing them. Meta-analytic reviews provide support for the general utility of RET, but more qualitative reviews question both the internal and external validity of much of the published research. Lacking are process studies that can shed light on the mechanisms of therapeutic change, a situation likely due to the complexity of RET and to a lack of consensus as well about its very definition. Perhaps more progress can be achieved by forsaking studies of RET as a package and shifting instead to examination of specific therapeutic tactics in particular circumstances.

Adaptation, Psychological↗
PubMed1993

Efficacy of rational-emotive therapy: a quantitative analysis.

Meta-analysis of 28 controlled studies on the efficacy of rational-emotive therapy (RET) showed RET to be superior to placebo and no treatment but equally effective in comparison with other types of treatment such as combination therapies and systematic desensitization. No support was found for the view that RET with a main or balanced emphasis on behavioral techniques is more efficacious than RET with a primarily or exclusively cognitive approach. However, given the heterogeneity of the set of studies and its relatively small sample size, interpretations of results have to be made with caution, particularly because evidence was found for a relationship between study characteristics and magnitude of effect size. For the sake of meta-analysis, outcome studies should be required to report at least the means and standard deviations for all experimental groups.

Clinical Trials as Topic↗
PubMed2005

No credit where credit is due: attributional rationalization of women's success in male-female teams.

In 3 experimental studies, the authors explored how ambiguity about the source of a successful joint performance outcome promotes attributional rationalization, negatively affecting evaluations of women. Participants read descriptions of a mixed-sex dyad's work and were asked to evaluate its male and female members. Results indicated that unless the ambiguity about individual contribution to the dyad's successful joint outcome was constrained by providing feedback about individual team member performance (Study 1) or by the way in which the task was said to have been structured (Study 2) or unless the negative expectations about women's performance were challenged by clear evidence of prior work competence (Study 3), female members were devalued as compared with their male counterparts-they were rated as being less competent, less influential, and less likely to have played a leadership role in work on the task. Implications of these results, both theoretical and practical, are discussed.

Achievement↗
PubMed2006

Dialysis rationing in South Africa: a global message.

Dialysis rationing resulting from limited facilities and health-care personnel in low- and middle-income countries such as South Africa must be addressed on several fronts. Prevention of kidney disease is an essential long-term approach, but in the short term, it is necessary to increase access to dialysis and transplantation, and to seek ways to limit the 'brain drain' to the developed world.

Decision Making↗
PubMed1997

The persistent vegetative state and anencephaly: problematic paradigms for discussing futility and rationing.

Medical futility has been a controversial issue for the last several years. Although anencephalic infants and patients in the persistent vegetative state (PVS) have often been suggested as paradigmatic cases for discussing the issue of medical futility, there is no consensus among physicians or ethicists that treatment of such patients is futile and courts have not supported the futility argument. Focusing on the issue of medical futility will not resolve the management issues surrounding the care of patients in PVS or anencephalic infants. Instead, an analysis of the benefits and burdens of treatments offers a potential solution by demonstrating that the real problem is the dissociation of the benefits and burdens of treatment for such patients. We propose the idea that anencephalic infants and patients in PVS provide an appropriate paradigm for discussing the issue of rationing of health-care resources.

Anencephaly↗
PubMed1990

Rational self-directed hypnotherapy: a treatment for panic attacks.

A single-subject research design was employed to assess the efficacy of rational self-directed hypnotherapy in the treatment of panic attacks. Presenting symptoms were acute fear, dizziness, constricted throat, upset stomach, loss of appetite, loss of weight, insomnia, fear of doctors, and fear of returning to work. Treatment lasted 13 weeks plus a 2-week baseline and posttherapy period and a 6-month follow-up. Objective measurements (MMPI, TSCS, POMS) and self-report assessments (physiological symptoms and a subjective stress inventory) were implemented. Using hypnosis and guided imagery, the subject reviewed critical incidents identifying self-defeating components within a cognitive paradigm, revising and rehearsing these incidents. Results showed an increased sense of control, improved self-concept, elimination of pathological symptoms, and cessation of panic attacks.

Adult↗
PubMed1992

Group rational-emotive and cognitive-behavioral therapy.

The theory of rational-emotive therapy (RET) and of cognitive-behavioral therapy (CBT) is briefly explained and is applied to group therapy. It is shown how RET and CBT therapy groups deal with transference, countertransference, levels of group intervention, process versus content orientation, identifying underlying group process themes, here-and-now activation, working with difficult group members, activity levels of therapist and group members, and other group problems. Although they particularly concentrate on people's tendencies to construct and create their own "emotional" difficulties, RET and CBT group procedures fully acknowledge the interactions of human thoughts, feelings, and actions and active-directively employ a variety of cognitive, emotive, and behavioral group therapy techniques.

Cognitive Behavioral Therapy↗
PubMed1984

Rational-emotive therapy in the treatment of erectile failure: an initial study.

Sixteen males with erectile failure, married or living with their partners, were assigned to either 12 bi-weekly sessions (6 weeks) of Rational Emotive Therapy (RET) or a 6-week waiting-list control group. Active treatment administered by a graduate student in psychology with special training in RET resulted in patients making significantly more sexual intercourse attempts, reporting significantly reduced sexual anxiety, and having a significantly higher number of successful intercourse attempts than the waiting-list control group. While 6-9 month follow-up revealed that most treated patients had fallen back toward the pretest baseline (lower rates of successful intercourse), group means as a whole were still significantly higher than pretreatment intercourse success rates. The significance of these findings are discussed.

Adult↗
PubMed1994

Oregon Health Plan: ration or reason.

The Oregon Health Plan gained national attention by changing the focus of health care from who is covered to what is covered. This change was facilitated by insurance reforms in the areas of small market, employer mandates, high risk pooling and Medicaid. Most controversial of the reforms is the use by the legislature of a prioritized list of health services to determine benefit levels for the insurance programs. Significant debate has occurred over whether the use of such a list is rationing or reasoning. The Oregon Health Plan represents a thoughtful and deliberate blending of fact with public value for the purpose of responsible health policy. It is that unique blending of public values developed through community participation with fact that focused the attention of the world on Oregon.

Community Participation↗
PubMed1995

The Norwegian welfare state in transition: rationing and plurality of values as ethical challenges for the health care system.

This paper presents the Norwegian national health care system and the manner in which the problems of rationing and pluralism of values create new ethical and political challenges. The paper concludes with some doubts about the feasibility of the transformation taking place within this kind of health care system, with special reference to governmental control and consumer preferences.

Community Participation↗
PubMed1998

The short-term health outcome of out-patient rheumatology consultations in relation to rationing: a pilot study.

The objectives were to test whether the short-term health outcome of rheumatology out-patients differs according to clinical priority. The setting was an NHS regional rheumatology out-patient department serving a catchment population of over 1 million. The subjects were 249 consecutive rheumatology out-patients categorized on the basis of the referral letter as 'urgent' (n = 50), 'soon' (n = 100) or 'routine' (n = 99). Primary outcome measures were the proportion of patients reporting improvement in health categorized by clinical priority (urgent, soon or routine) or main diagnostic group (inflammatory or non-inflammatory disease). Secondary outcome was change in health status measured using the EuroQol generic health instrument (EQ-5D). Small but insignificant differences in the proportion of patients reporting health improvement were found between the urgent (28%), soon (23%) and routine (17%) categories (Kruskal-Wallis, P = 0.186). Thirty per cent of patients with inflammatory joint disease reported improvement compared with 17% of those with non-inflammatory conditions (Mann-Whitney U, P = 0.019). In patients reporting improvement, the median (interquartile range) improvement in EQ-5D health utility score was +0.2 (0.58) (P = 0.0001) and that of visual analogue health score was +5 (16) (P = 0.001). Clinical priority setting, by giving priority to some patients over others, results in rationing by delay. These data do not support the hypothesis that fewer patients given a low clinical priority gain health benefit compared with those given a high priority. However, those with inflammatory joint disease do appear to have better short-term health outcomes.

Adolescent↗
PubMedDate not supplied

Rationing influenza vaccine: Legal strategies and considerations for local health officials.

Despite the fact that influenza vaccine is an important health resource, the structure and organization of the US vaccine manufacturing system has produced influenza vaccine shortages or distribution delays in five out of the last six influenza seasons. These shortages have produced the need for local public health officials to develop protocols for rationing and redistributing influenza vaccine at the local community level. In so doing, local health officials are confronted with significant practical and legal constraints associated with allocating a resource that is largely not under direct government control. In the face of an impending influenza vaccine shortage, local public health departments endeavor to do three things: (1) assess the local supply of vaccine, (2) assess the local demand from high-risk community members, and (3) ensure that to the greatest extent, the limited local supply of vaccine is used exclusively by those at highest risk within the local jurisdiction. There are a number of legal tools and strategies that local health officials have at their disposal to carry out these functions. This article will attempt to outline some of the significant legal impediments and practical constraints that local public health officials face in managing influenza vaccine supply-demand issues and will offer some suggestions for strengthening their ability to effectively manage these increasingly common situations.

Community Health Services↗
PubMed2002

Rationing mental health care: parity, disparity, and justice.

Recent policy debates in the US over access to mental health care have raised several philosophically complex ethical and conceptual issues. The defeat of mental health parity legislation in the US Congress has brought new urgency and relevance to theoretical and empirical investigations into the nature of mental illness and its relation to other forms of sickness and disability. Manifold, nebulous, and often competing conceptions of mental illness make the creation of coherent public policy exceedingly difficult. Referencing a variety of approaches to ethical reflection on health care, and drawing from the empirical literature on therapeutic efficacy and economic efficiency, we argue that differential rationing, 'disparity,' is unjustifiable.

Ethical Analysis↗