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PubMedDate not supplied

Using cost-effectiveness/cost-benefit analysis to allocate health resources: a level playing field for prevention?

INTRODUCTION: Prevention is being promoted as a means to improve health status and to save health care costs. Economic evaluations of prevention (i.e., cost-effectiveness and cost-benefit analyses) indicate that some prevention activities, like many treatments, do not save money, although many are relatively cost-effective. It has been suggested, however, that prevention is held to a higher standard than treatment because prevention programs are expected to demonstrate cost savings, and that the methods of economic evaluation understate the cost-effectiveness of prevention. Although the converse assertion is less commonly made, economic evaluations may also overstate the cost-effectiveness of prevention. The purpose of this article is to examine how the methods of economic evaluation may systematically understate, or overstate, the cost-effectiveness (or net benefits) of prevention. METHODS: We examine three key methods: (1) how future costs and benefits are valued ("discounting"), (2) how costs and benefits to people beyond those who are the users of prevention are valued ("externalities"), and (3) how nonmonetary costs and benefits to individuals are valued ("intangibles"). RESULTS: We discuss several recommendations for each key method, and we use a hypothetical example of the cost-effectiveness of a vaccine to prevent human immunodeficiency virus (HIV) to illustrate our points. CONCLUSIONS: We conclude that the methods of economic evaluation may both understate and overstate the cost-effectiveness of prevention.

Cost-Benefit Analysis↗
PubMed1991

The principle of QALY maximisation as the basis for allocating health care resources.

This paper presents a case for allocating health care resources so as to maximise Quality Adjusted Life Years (QALYs). Throughout parallels are drawn with the grounds for adopting utilitarianism. QALYs are desirable because they are essential for human flourishing and goal-attainment. In conditions of scarcity the principle of QALY maximisation may involve unequal treatment of different groups of people; and it is argued that this is not objectionable. Doctors in their dealings with patients should not be continually consulting the principle (though it can sometimes be useful); instead by following existing ethical codes more QALYs will be produced overall. In the formulation of policy, however, the principle should be applied in a thoroughgoing way and, if it is, it will not have some of the counterintuitive consequences it may have in interpersonal situations.

Decision Making↗
PubMed2002

Consequences of hierarchical allocation for the evolution of life-history traits.

Resource allocation within individuals may often be hierarchical, and this may have important effects on genetic correlations and on trait evolution. For example, organisms may divide energy between reproduction and somatic growth and then subdivide reproductive resources. Genetic variation in allocation to pathways early in such hierarchies (e.g., reproduction) can cause positive genetic correlations between traits that trade off (e.g., offspring size and number) because some individuals invest more resources in reproduction than others. We used quantitative-genetic models to explore the evolutionary implications of allocation hierarchies. Our results showed that when variation in allocation early in the hierarchy exceeds subsequent variation in allocation, genetic covariances and initial responses to selection do not reflect trade-offs occurring at later levels in the hierarchy. This general pattern was evident for many starting allocations and optima and for whether traits contributed multiplicatively or additively to fitness. Finally, artificial selection on a single trait revealed masked trade-offs when variation in early allocation was comparable to subsequent variation in allocation. This result confirms artificial selection as a powerful, but not foolproof, method of detecting trade-offs. Thus, allocation hierarchies can profoundly affect life-history evolution by causing traits to evolve in the opposite direction to that predicted by trade-offs.

Animal Population Groups↗
PubMed1990

A clinician's guide to cost-effectiveness analysis.

Cost-effectiveness analysis can be used to help set priorities for funding health care programs. For each intervention, the costs and clinical outcomes associated with that strategy must be compared with an alternate strategy for treating the same patients. If an intervention results in improved outcomes but also costs more, the incremental cost per incremental unit of clinical outcome should be calculated. The incremental cost-effectiveness ratios for various programs can be ranked to set funding priorities. By using this list, the person responsible for allocating resources can maximize the net health benefit for a target population derived from a fixed budget. Clinicians may not share this objective because, individually, they are appropriately concerned solely with the effectiveness of a specific intervention for their patients and are not concerned with the benefit derived from spending those resources on other patients in the target population. In addition, allocation may be driven by distributional and political objectives. Nevertheless, cost-effectiveness analysis demonstrates the consequences of allocation decisions. Because clinicians should participate in policy making, they must understand d the role of this technique in setting funding priorities.

Cost-Benefit Analysis↗
PubMedDate not supplied

Optimal investment in a portfolio of HIV prevention programs.

OBJECTIVES: In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes. METHODS: The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior. RESULTS: The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit. CONCLUSIONS: The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

Community Health Planning↗
PubMed1996

Ethics and the care of critically ill infants and children. American Academy of Pediatrics Committee on Bioethics.

The ability to provide life support to ill children who, not long ago, would have died despite medicine's best efforts challenges pediatricians and families to address profound moral questions. Our society has been divided about extending the life of some patients, especially newborns and older infants with severe disabilities. The American Academy of Pediatrics (AAP) supports individualized decision making about life-sustaining medical treatment for all children, regardless of age. These decisions should be jointly made by physicians and parents, unless good reasons require invoking established child protective services to contravene parental authority. At this time, resource allocation (rationing) decisions about which children should receive intensive care resources should be made clear and explicit in public policy, rather than be made at the bedside.

Bioethics↗
PubMed1983

Allocation of family resources for health care in rural Haiti.

A household survey of 230 episodes of infant and child illness in rural Haiti was analyzed to identify sociocultural and environmental factors that determine allocation of family resources for health care. The analysis tested the hypothesis that expenditures of time and money would vary according to expectations about the prognosis for the disease in question, the age and sex of the child, the household composition and family structure, and seasonal fluctuations in weather and financial resources. The results show that these factors are significant predictors of resource allocation, although they do not always produce the kind of influence that was hypothesized. The findings emphasize the importance of cultural and ecological variables, as well as of purely medical and economic factors, in understanding family response to illness. The importance of nonmonetary resources (such as the free time available to adult family members) in that response is also indicated. The study has methodological and practical implications for Haiti and other areas.

Adolescent↗
PubMed2006

Linking case management and community development.

Case management, in various forms, is now institutionalized as a core part of policy and programs designed to deliver home- and community-based services to older adults. The case management role, in theory, requires attention to both client and system goals, although in practice the system goals that have received most attention have been gatekeeping and resource allocation. While case managers have been admonished to find and develop resources in the community, this has primarily taken the form of including informal services in individual client care plans. What has been missing is focused attention to the potential of the community as a nurturing environment with the capacity to support older adults and their caregivers. Sustainable care for older adults cannot be achieved by formal service and family support alone. This article proposes the creation of linkages between case managers, who build the service arrangements for older people, and community developers, who are responsible for building community capacity and social capital. It is argued that this linkage is essential for establishing the foundations of a caring community with the capacity to support older people.

Aged↗
PubMed1990

Allocation of medical resources: problems faced by the practicing neurosurgeon.

The allocation of medical resources by the neurosurgeon begins with the patient-physician relationship and is increasingly affected by managers of third-party payers, the desire for patient autonomy, quality assurance regulation, state regulatory requirements, and the present recriminatory legal system. In addition, fiscal constraints within institutions impact on decisions regarding the allocation of medical resources by the physician. Beyond these micro-allocation problems lie the macro-allocation difficulties at the levels of state and federal government, where concepts of equality and justice--as they relate to allocation of resources--are altered by political forces; aging populations; new, devastating diseases; availability of rapidly improving technical, diagnostic, and treatment modalities; and the attendant costs and related tax burdens on the populace.

Government Regulation↗
PubMed2004

Adult mental health needs and expenditure in Australia.

BACKGROUND: Relatively little international work has examined whether mental health resource allocation matches need. This study aimed to determine whether adult mental health resources in Australia are being distributed equitably. METHOD: Individual measures of need were extrapolated to Australian Areas, and Area-based proxies of need were considered. Particular attention was paid to the prevalence of mental health problems, since this is arguably the most objective measure of need. The extent to which these measures predicted public sector, private sector and total adult mental health expenditure at an Area level was examined. RESULTS: In the public sector, 41.6% of expenditure variation was explained by the prevalence of affective disorders, personality disorders, cognitive impairment and psychosis, as well as the Area's level of economic resources and State/Territory effects. In the private sector, 72.4% of expenditure variation was explained by service use and State/Territory effects (with an alternative model incorporating service use and State/Territory supply of private psychiatrists explaining 69.4% of expenditure variation). A relatively high proportion (58.7%) of total expenditure variation could be explained by service utilisation and State/Territory effects. CONCLUSIONS: For services to be delivered equitably, the majority of variation in expenditure would have to be accounted for by appropriate measures of need. The best model for public sector expenditure included an appropriate measure of need but had relatively poor explanatory power. The models for private sector and total expenditure had greater explanatory power, but relied on less appropriate measures of need. It is concluded that mental health services in Australia are not yet being delivered equitably.

Adolescent↗
PubMed1995

Rationing health care and the need for credible scarcity: why Americans can't say no.

With adequate cost containment unlikely in the foreseeable future, health care use will have to be curtailed, ideally with open and explicit criteria for equitably allocating resources or rationing. Yet, consensus on any such criteria appears remote because Americans cannot say no to health care. Americans may refuse to accept rationing for two reasons. The absence of any global limitation on health care resources may encourage patients to believe that health care resources are not scarce and do not need to be rationed. A belief in vitalism--that everyone is morally entitled to unlimited longevity and good health--may discourage setting limits on one's own care. Together, these characteristics may foster the belief that denials of health care services, especially by health insurers, are arbitrary or unfair refusals to pay for existing resources and not a necessary method of rationing scarce resources. If this hypothesis is true, Americans are unlikely to achieve consensus on any equitable allocation of health care unless they face an actual shortage (credible scarcity) of health care resources that makes it necessary to ration care.

Attitude to Health↗
PubMedDate not supplied

Trendstar at Flinders Medical Centre.

Trendstar provides Flinders Medical Centre with a reliable management tool that facilitates appropriate resource allocation and ensures that those resources are utilised efficiently. The system supports our aim to provide high quality, cost effective care for our clients.

Accounting↗
PubMed2003

Effects of diet and Echinostoma revolutum infection on energy allocation patterns in juvenile Lymnaea elodes snails.

Resource allocation strategies may be influenced by both biotic and abiotic factors. The purpose of this study was to investigate the effects of both parasitism and diet quality on the growth, reproduction, and survival of the pond snail, Lymnaea elodes. In addition, we assessed parasite growth and reproduction. High-protein (high diet) or low-protein diets (low diet) were fed to juvenile L. elodes snails that were either exposed or sham-exposed to the castrating trematode, Echinostoma revolutum. Host growth was assessed weekly; reproduction and survival were recorded every 2-3 days. We estimated parasite development as the time to parasite release from the host (patency), and parasite reproduction as the number of larvae shed from infected snails at two time points. Diet and infection status had significant effects on snail growth. Infected snails produced few eggs and tended to grow to larger sizes than uninfected snails regardless of diet. In contrast, exposed-uninfected individuals displayed diet-dependent patterns of growth and reproduction. On the high-protein diet, uninfected and exposed-uninfected snails exhibited similar patterns of growth and reproduction, whereas in the low-diet treatment, exposed-uninfected snails exhibited reduced growth and delayed reproduction relative to uninfected individuals. Survival differed among treatments in the latter stages of the study with infected snails exhibiting reduced survival relative to snails from other treatments. Moreover, infected low-diet snails exhibited lower survival than infected high-diet snails. Parasite development and reproduction did not appear to be directly influenced by the quality of host diet. Results from this study suggest that energy allocation patterns are context-dependent in juvenile snails, influenced by parasite exposure and diet quality. Furthermore, parasite reproduction appears to depend more on host size than on the quality of host diet.

Animals↗
PubMed2002

Improving equity in the provision of primary health care: lessons from decentralized planning and management in Namibia.

This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces.

Community Health Centers↗
PubMed2005

A strategy for allocating central funds to support new faculty recruitment.

Requests for central funding for recruiting new faculty in academic health centers (AHCs) typically exceed available resources. The administration's prioritization of the requests, therefore, involves implicit or explicit predictions of the value of the potential faculty member to the institution. Optimal management dictates that the value of the recruit be assessed both on the extent to which they contribute to the organization's mission and on their capacity to generate revenues. The first premise of this article is that faculty recruits can be considered as "projects," and their potential value to the organization can be estimated in this context. The second premise is that the best way to determine a project's financial worth is by determining the net present value of each potential faculty recruit. The author models the combination of these premises and demonstrates that the approach allows for the more systematic prioritization of resource allocation for faculty recruitment in AHCs.

Academic Medical Centers↗
PubMed1996

Mission simulation as an approach to develop requirements for automation in Advanced Life Support Systems.

This paper examines mission simulation as an approach to develop requirements for automation and robotics for Advanced Life Support Systems (ALSS). The focus is on requirements and applications for command and control, control and monitoring, situation assessment and response, diagnosis and recovery, adaptive planning and scheduling, and other automation applications in addition to mechanized equipment and robotics applications to reduce the excessive human labor requirements to operate and maintain an ALSS. Based on principles of systems engineering, an approach is proposed to assess requirements for automation and robotics using mission simulation tools. First, the story of a simulated mission is defined in terms of processes with attendant types of resources needed, including options for use of automation and robotic systems. Next, systems dynamics models are used in simulation to reveal the implications for selected resource allocation schemes in terms of resources required to complete operational tasks. The simulations not only help establish ALSS design criteria, but also may offer guidance to ALSS research efforts by identifying gaps in knowledge about procedures and/or biophysical processes. Simulations of a planned one-year mission with 4 crewmembers in a Human Rated Test Facility are presented as an approach to evaluation of mission feasibility and definition of automation and robotics requirements.

Automation↗
PubMed2006

Interactive effects of habitat productivity and herbivore pressure on the evolution of anti-herbivore defense in invasive plant populations.

The evolution of increased competitive ability (EICA) hypothesis predicts that plants released from natural enemies should evolve to become more invasive through a shift in resource allocation from defense to growth. Resource availability in the environment is widely regarded as a major determinant of defense investment and invasiveness, and thus should be incorporated into the conceptual framework of EICA. Analysis of a simple model from the optimal defense literature demonstrates that, in contrast to the EICA hypothesis, enemy release is neither sufficient nor necessary for evolution of reduced resistance among introduced plants when habitat productivity co-varies. In particular, if the invasive range is more nutrient-poor than the native range, there could be selection for more plant defenses even with enemy release.

Animals↗