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PubMed2001

Constructing "sound science" and "good epidemiology": tobacco, lawyers, and public relations firms.

The tobacco industry has attacked "junk science" to discredit the evidence that secondhand smoke-among other environmental toxins-causes disease. Philip Morris used public relations firms and lawyers to develop a "sound science" program in the United States and Europe that involved recruiting other industries and issues to obscure the tobacco industry's role. The European "sound science" plans included a version of "good epidemiological practices" that would make it impossible to conclude that secondhand smoke-and thus other environmental toxins-caused diseases. Public health professionals need to be aware that the "sound science" movement is not an indigenous effort from within the profession to improve the quality of scientific discourse, but reflects sophisticated public relations campaigns controlled by industry executives and lawyers whose aim is to manipulate the standards of scientific proof to serve the corporate interests of their clients.

Carcinogens↗
PubMed1991

Principles for funding on a case mix basis: construction of case weights (RIWs).

The construct of Resource Intensity Weights (RIWs) contains implicit financial incentives if they are used for hospital funding purposes. This paper compares the RIW (funding) credit to the expected average per diem cost for each of the new subcategories (typicals, deaths, transfers, signouts and outliers) of Case Mix Groups (CMGs). RIW construction, and inherent incentives for a hospital to reduce costs or length of stay (LOS), differ significantly for each subcategory. At some point or points in a patient's LOS, when RIW credit equals case cost, RIWs are incentive neutral. However, it can also be demonstrated that RIW credit is not generally congruent with average costs on each day of a patient's stay. Financial incentives (both positive and negative) arise when RIW credit and costs differ. Only by being fully aware of these differences can hospitals determine how to respond to the introduction of case mix funding to maintain financial viability. Funding agencies, too, need to appreciate the sometimes subtle policy implications that come with the adoption of RIWs for funding purposes.

Accounting↗
PubMed2000

Sensory and movement-led approach to design for elderly severely mentally ill units.

The evolution of a design embodying the alliance of movement to sensory stimulus for confused and Alzheimer sufferers. The paper is an account of the design concept of an Elderly Severely Mentally Ill (ESMI) unit under the Government Private Finance Initiative (PFI) rules. Previous papers by the author recorded the development of elderly care nursing units that sought to use the planning of circulation as a means to provide stimulation for patients. The results demonstrated a therapeutic value for this approach. In the latest version for ESMI, the concept has been taken further with the creation of a "Memory Trail" that provides a choice of routes with organised points of interest containing stimulus for the senses in order to trigger memory. This is seen as beneficial not only for patient but also provides a positive role for relatives in escorting and planning the "journey". The paper records how the design amended the original brief by the participation of user groups re-evaluating the requirements in discussion and visits to earlier versions of this approach.

Aged↗
PubMed1999

PROFILE: Levying of Ecoenvironmental Compensation Fees in China: An Analysis and Proposals.

/ The levying of ecoenvironmental compensation fees on China's resource exploitation and construction activities, which can cause ecological damage, has been proposed as one effective means to help better manage China's present ecological and environmental problems. Such a fee, however, has not been adopted on a national scale, although small-scale experiments are underway. Using the experience of developed countries as a guide, a policy reform to institute ecoenvironmental compensation fees would require wide-ranging studies and analyses. These would have to include both theoretical and practical investigations on subjects including, but not limited to, methods for setting fees, managing their implementation, and the full range of their impacts (environmental, economic, and social). This article identifies guidelines for the principles and objectives to cover the proposed levy as well as proposals for fee collection and the subsequent these levies.In addition to estimating the total amount of the ecoenvironmental levies, the article analyzes the fee's quantitative effects on the government's major price indexes. Assuming fee collection started in calendar year 1998, total revenues collected by the end of the year 2000 are estimated to range from 6.68 billion Renminbi (RMB, unit of money used in China; 1990's comparative value, the same thereafter), 12.6 billion RMB, to 18.6 billion RMB, depending on the fee rate in question. The revenue collected in this way would, if used to finance environmental reclamation projects, greatly improve important parts of China's endangered environment. Moreover, our calculations indicate that fee collection would likely not lead to significant price fluctuations.KEY WORDS: Ecoenvironmental compensation fee; Levy; Chinahttp://link.springer-ny.com/link/service/journals/00267/bibs/24n3p353.html

Journal Article↗
PubMed2001

Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India.

Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.

Adolescent↗
PubMed2000

A meta-analytic approach to growth curve analysis.

A meta-analytic approach to growth curve analysis is described and illustrated by applying it to the evaluation of the Arizona Pilot Project, an experimental project for financing the treatment of the severely mentally ill. In this approach to longitudinal data analysis, each individual subject for which repeated measures are obtained is initially treated as a separate case study for analysis. This approach has at least two distinct advantages. First, it does not assume a balanced design (equal numbers of repeated observations) across all subjects; to accommodate a variable number of observations for each subject, individual growth curve parameters are differentially weighted by the number of repeated measures on which they are based. Second, it does not assume homogeneity of treatment effects (equal slopes) across all subjects. Individual differences in growth curve parameters representing potentially unequal developmental rates through time are explicitly modeled. A meta-analytic approach to growth curve analysis may be the optimal analytical strategy for longitudinal studies where either (1) a balanced design is not feasible or (2) an assumption of homogeneity of treatment effects across all individuals is theoretically indefensible. In our evaluation of the Arizona Pilot Project, individual growth curve parameters were obtained for each of the 13 rationally derived subscales of the New York Functional Assessment Survey, over time, by linear regression analysis. The slopes, intercepts, and residuals obtained for each individual were then subjected to meta-analytic causal modeling. Using factor analytic models and then general linear models for the latent constructs, the growth curve parameters of all individuals were systematically related to each other via common factors and predicted based on hypothesized exogenous causal factors. The same two highly correlated common factors were found for all three growth curve parameters analyzed, a general psychological factor and a general functional factor. The factor patterns were found to be nearly identical across the separate analyses of individual intercepts, slopes, and residuals. Direct effects on the unique factors of each subscale of the New York Functional Assessment Survey were tested for each growth curve parameter by including the common factors as hierarchically prior predictors in the structural model for each of the indicator variables, thus statistically controlling for any indirect effect produced on the indicator through the common factors. The exogenous predictors modeled were theoretically specified orthogonal contrasts for Method of Payment (comparing Arizona Pilot Project treatment or "capitation" to traditional or "fee-for-service" care as a control), Treatment Administration Site (comparing various locations within treatment or control groups), Pretreatment Assessment (comparing general functional level at intake as assigned by an Outside Assessment Team), and various interactions among these main effects. The intercepts, representing the initial status of individual subjects on both the two common factors and the 13 unique factors of the subscales of the New York Functional Assessment Survey, were found to vary significantly across many of the various different treatment conditions, treatment administration sites, and pretreatment functional levels. This indicated a severe threat to the validity of the originally intended design of the Arizona Pilot Project as a randomized experiment. When the systematic variations were statistically controlled by including intercepts as hierarchically prior predictors in the structural models for slopes, recasting the experiment as a nonequivalent groups design, the effects of the intercepts on the slopes were found to be both statistically significant and substantial in magnitude. (ABSTRACT TRUNCATED)

Capitation Fee↗
PubMed2006

Moral hazard or realised access to care? Empirical observations in Hong Kong.

We examined for the presence of moral hazard among those covered by medical benefits or insurance schemes, whether provided for by employers or privately purchased and stratified by health care provider sector in Hong Kong. Data for this study were derived from the 2002 Thematic Household Survey, covering 24,610 non-institutional residents aged 15 and over, representing 5,353,666 persons after applying population weights. Zero-inflated Poisson or negative binomial models were constructed to examine the association between predisposing, need and enabling factors with inpatient and outpatient utilisation patterns as per Andersen's health behavioural framework. Individuals with insurance or medical benefits were more likely to have been ever admitted in the previous year but did not incur more bed-days. Similarly, those who were covered by insurance or medical benefits had a higher probability of ever visiting a doctor in the previous month but not consuming more episodes. These findings were consistent across the public and private sectors. We propose that our observations mostly reflected realised access that met genuine health need rather than inappropriate overuse of services. A supply-driven public sector and high out-of-pocket co-payments for private services likely explained these findings.

Adolescent↗
PubMed2004

Therapy by design: evaluating the UK hospital building program.

A renewed interest in hospital design in the UK, prompted by the Private Finance Initiative, provides an opportunity to consider hospitals as 'therapeutic environments'. Noting that the therapeutic value of hospitals is related to their physical, social and symbolic design, this paper argues that 'expert' knowledges have encouraged the development of hospitals that all-too-rarely provide benign settings for promoting patient recovery and healing. The recent programme of hospital building in the UK, however, has been accompanied by a vigorous debate over what constitutes good hospital design, with four significant ideas emerging: hospitals should be clinically efficient, be integrated within the community, be accessible to consumers and the public, and encourage patient and staff well-being. Suggesting that all four goals demand careful consideration of the real and imagined spatiality of hospital environments, the paper concludes by suggesting ways that health geographers can contribute to debates surrounding PFI hospital design.

Hospital Design and Construction↗
PubMed2002

Association of willingness to pay with severity of chronic obstructive pulmonary disease, health status and other preference measures.

SETTING: Willingness to pay (WTP) is a method frequently used to measure the benefits of health interventions in monetary terms. OBJECTIVE: To assess the construct validity of the WTP method in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Fifty-nine COPD patients (34 men, mean age 57 years) were asked about their maximum WTP for a theoretical cure for COPD. In addition, they reported utility scores using standard gamble, time trade-off, a multi-attribute utility instrument, and a rating scale. They also responded to the Short Form 36 (SF-36) questionnaire, dyspnea measures and had comprehensive pulmonary function tests. RESULTS: The participants reported a median WTP of Norwegian kroner 200 000 (US $24 096) for a theoretical cure for COPD without side-effects. The associations of WTP with utility scores, dimensions of health status, dyspnea measures and lung function tests were low. CONCLUSION: The findings of this study question the validity of the WTP method in patients with chronic obstructive pulmonary disease.

Adult↗
PubMed1994

Alternative technique of constructing bilateral cleft palate in late childhood: a case report and literature review.

Although great advances in treatment of oro-facial clefts have been made over the past 50 years; in developing countries, due to social stigmas and unavailability of specialised medical facilities and personnel to the majority of the population, there is an increasing incidence of patients coming late for repair of oro-facial clefts. This presents a challenge to both plastic, oral surgeons and associated specialists. The aim of the present article is to demonstrate, in the form of a case report, an alternative surgical technique that has be successful in 8 cases for the late repair of severe bilateral cleft palate utilizing locally available and affordable materials. The objective of managing patients with cleft palate in developing countries is to provide the best repair and rehabilitation with as few operations and in-patient care as possible due to limited financial resources experienced by the majority of in-patients. A multidisciplinary approach to the management of oro-facial clefts is emphasised.

Alveolar Process↗
PubMed1980

The impact of Hill-Burton: an analysis of hospital bed and physician distribution in the United States, 1950-1970.

The Hospital Survey and Construction Act of 1946, commonly known as the Hill-Burton Act, was intended to improve the supply, distribution and quality of general hospital beds across the United States. Some also saw the program as a means of affecting the supply and distribution of physicians. The strategy used here for evaluating the Hill-Burton program derives in part from the assumptions about health resources supplies on which Hill-Burton policy was found and in part from a model of socioeconomic convergence developed in public policy research on the American states. Major conclusions include 1) Hill-Burton had a major redistributive impact on state bed supplies; 2) physician redistribution lagged far behind progress in bed redistribution; and 3) interstate distribution of physicians appears to have been unaffected by Hill-Burton-associated bed redistribution, a finding contrary to other work in this area.

Beds↗
PubMed2005

Fund allocation within Australian dental care: an innovative approach to output based funding.

BACKGROUND: Over the last 15 years in Australia the process of funding government health care has changed significantly. The development of dental funding models that transparently meet both the service delivery needs for data at the treatment level and policy makers' need for health condition data is critical to the continued integration of dentistry into the wider health system. METHODS: This paper presents a model of fund allocation that provides a communication construct that addresses the needs of both policy makers and service providers. RESULTS: In this model, dental treatments (dental item numbers) have been grouped into eight broad dental health conditions. Within each dental health condition, a weighted average price is determined using the Department of Veterans Affairs' (DVA) fee schedule as the benchmark, adjusted for the mix of care. The model also adjusts for the efficiency differences between sectors providing government funded dental care. In summary, the price to be applied to a dental health condition category is determined by the weighted average DVA price adjusted by the sector efficiency. CONCLUSIONS: This model allows governments and dental service providers to develop funding agreements that both quantify and justify the treatment to be provided. Such a process facilitates the continued integration of dental care into the wider health system.

Australia↗
PubMed1991

Designing a deprivation payment for general practitioners: the UPA(8) wonderland.

OBJECTIVE: To analyse critically the deprived area payment introduced in the new general practitioner contract. The payment formula is based on the Jarman underprivileged area index (UPA(8)) and aims at compensating general practitioners for increases in workload. DESIGN: Evaluation of the deprived area payment against the stated policy objective with a set of criteria for developing resource allocation formulas. MAIN OUTCOME MEASURES: The degree to which the components of the Jarman index predict the workload of general practitioners; whether construction of the index is sensible and comprehensible; and how the formula incorporates the index and is likely to work in practice. RESULTS: The fact that the index relies on census data and the way the weighting was derived means that the formula will not accurately reflect the workload. The use of statistical transformations obscures the original policy intent. There has been no validation to support the application of the index as part of a national policy. The payments are not linked to the quality of service provided and may have the perverse effect of increasing list size. CONCLUSION: The formula used as the basis of the deprived area payments is poorly suited to the policy objective of compensating general practitioners for increases in workload. More research is urgently needed to enable the effect of the payment to be monitored and a more empirically sound set of incentives to be developed.

Family Practice↗
PubMed1979

Introduction to the theme--state intervention and the social wage: the politics of social services expansion.

State intervention in the consumption process has become increasingly critical to economic growth on the one hand and to real family income on the other. The social wage thus tends to become a conflictual political issue. As a result, the articulation of state intervention with the changing requirements of economic growth is subject to continuous political challenge. This special issue examines the problematic relationship between state intervention in social services and the organization of the capitalist economy. Some contributors study the ways in which state inter ventions are structured so as to be consonant with the requirements of economic growth and profitability, as well as the difficulties such structures pose. Feshbach's analysis of the Hill-Burton Hospital Construction Program and Mollenkopf's study of San Francisco's public transit system both reflect this concern. Other contributors study the ways in which the organization of the economy constrains the development of democratically responsive social services. Sbragia's study of the capital market and public housing in Italy and Taylor's study of free medical clinics in the U.S. both reflect this concern. Finally, contributors study macroscopic transformations in the relationship between state intervention and the organization of the capitalist economy. Esping-Andersen's study of the political logic of increasing state intervention in production and Hirschhorn's analysis of the defunctionalization of social services attendent upon the disaccumulative tendencies in capitalism both reflect this concern. This introductory paper reviews four theories which attempt to explain how state intervention is insulated from democratic controls. For each theory, the mechanisms specified to perform this function are subject to weaknesses. An attempt is made to position the contributions to this volume with respect to these theoretical traditions.

Conflict, Psychological↗
PubMed2006

Gifts, bribes and solicitions: print media and the social construction of informal payments to doctors in Taiwan.

The Taiwanese practice of patients giving informal payments to physicians to secure services is deeply rooted in social and cultural factors. This study examines the portrayal of informal payments by Taiwanese print news media over a period of 12 years-from prior to until after the implementation of national health insurance (NHI) in Taiwan in 1995. The goal of the study was to examine how the advent of NHI changed the rationale for and use of informal payments. Both before and after the introduction of NHI, Taiwanese newspapers portrayed informal payments as appropriate means to secure access to better health care. Newspaper accounts established that, although NHI reduced patients' financial barriers to care, it did not change deeply held cultural beliefs that good care depended on the development of a reciprocal sense of obligation between patients and physicians. Physicians may have also encouraged the ongoing use of informal payments to make up revenue lost when NHI standardized fees and limited income from dispensing medications. In 2002, seven years after the implementation of NHI, the use of informal payments, though illegal, was still being justified in the print media through allusions to its role in traditional Taiwanese culture.

Financing, Personal↗
PubMed2004

Stated and actual altruistic willingness to pay for insecticide-treated nets in Nigeria: validity of open-ended and binary with follow-up questions.

OBJECTIVES: To determine whether the binary with follow-up (BWFU) or open-ended (OPED) contingent valuation question format would yield better valid estimates of altruistic willingness to pay (WTP) and examine the feasibility of using intra-community altruistic contributions to procure insecticide-treated nets (ITNs) for the poor in Nigeria. METHODS: Structured questionnaires were used to elicit stated altruistic WTP from a random sub-sample of respondents that had either the OPED or BWFU used to elicit WTP in Southeast Nigeria. One month after the survey the respondents were asked to redeem their WTP pledges. Construct validity was determined using econometric analyses, while phi correlation coefficient was used to determine criterion validity. FINDINGS: More than 57% of the respondents were hypothetically willing to pay for altruism in both BWFU and OPED groups. Altruistic WTP was positively related to respondents' WTP for own nets (p<0.01) and nets for other household members (p<0.05) in both groups. A total of 27.0% and 33.1% of the respondents with positive hypothetical WTP in the BWFU and OPED actually contributed. Phi correlation coefficient was 0.23 (95%CI 0.20-0.29) in BWFU and 0.49 (95%CI 0.44-0.54) in OPED. The money realised was used to buy some ITNs, which were presented to poor people selected by community leaders. CONCLUSION: The OPED elicited better valid estimates of altruistic WTP than BWFU. The potential for more capable people to contribute for the poor in ITNs programmes actually exist and malaria control programmes should explore altruistic contributions as a means to increase net coverage.

Adult↗
PubMed2002

QALYs, standard gambles, and the expected budget constraint.

This paper shows that when quality adjustment factors for use in constructing QALY indices are established through answers to standard-gamble questions or similar methods, the assumptions that are made by respondents about the financial consequences of changing probabilities of illness and death are critically important for the use of QALYs in cost-utility analysis (CUA). It qualifies Meltzer's [Journal of Health Economics 16 (1997) 33] result that the cost per quality-adjusted life-year (QALY) for life-saving medical interventions should include the future consumption of those who would otherwise not have survived, by showing that its validity depends on how the QALY index has been established. The paper also shows that, contrary to a widely held notion, allocation of a fixed health care budget through CUA does not generally result in a second-best efficient allocation. Another finding is that failure to specify carefully what respondents to standard-gamble questions are supposed to assume about the financial consequences of ill health may result in a bias against providing care to older individuals.

Aged↗
PubMed1994

Social trajectories and diversity of careers: two aspects of the evolution of the medical profession in France (1925-1989).

Over the last 50 years or so, the medical profession has undergone a profound transformation. In France, the boundaries of this period are marked by two decisive factors: construction of a system of collective funding of the services offered to the public by the medical profession; the need to control the increasing cost of medical services. At the same time, the adoption of an organized and permissive approach to funding has created a protected market and greater medicalization of the different strata of society through a specific process of professionalization of medicine. We point out the implications of these processes. It is assumed that public funding has extended the scope of liberal medical practice without physicians themselves being fully aware of the advantages and the resulting economic benefits it has brought them, i.e. its effects in terms of easier acquisition of wealth. These assumptions are based on two aspects of the data collected in the course of an extensive survey of 5491 retired French doctors: 1. Analysis of data concerning the social origins and mobility of physicians. 2. Analysis of the medical careers of physicians, diversification of professional orientation over time and physicians' incomes.

Aged↗