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At least 1,081 records · Page 60Linked to original sources
PubMed1998

Have we treated AIDS too well? Rationing and the future of AIDS exceptionalism.

During the past decade, medical therapy for AIDS has become more effective but also prohibitively expensive. A medical tragedy has been transformed into a financial crisis, and society has responded by establishing special programs and sources of funding for AIDS. These maneuvers parallel earlier approaches to HIV testing and reporting that have collectively come to be known as 'exceptionalism.' This paper suggests that exceptionalism in resource allocation is a fragile, short-term solution. In the long run, AIDS exceptionalism will create growing injustice and should be avoided. However, we should not eliminate the advances that this exceptionalism has already achieved. Instead, we need a working dialogue between these advances and public policy.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Justice in the allocation of public resources to disabled citizens.

This paper examines several crucial questions concerning justice in the allocation of public resources to disabled citizens. It challenges the current failure to means-test certain programs, and it argues that fundamental choices about levels of funding and about priorities in nonentitlement programs cannot be justified without a better theory of social justice.

Persons with Disabilities↗
PubMed2001

A defense of visible health care rationing.

Health care rationing, when defined as resource allocation that makes use of a power relationship, is inescapable in every health care system. Central to this paper is the question: Is visible (publicized and centralized) health care rationing a requirement of justice or an affront to public morality? Inasmuch as health care is a public good, it is argued that health care resources should be visibly rationed in order to satisfy prevailing notions of procedural justice.

Community Participation↗
PubMed2004

[Medical certificates issued to help the patient].

BACKGROUND: Medical certificates form the basis for important decisions in society, e.g. the issuing of a driver's licence or the granting of a disability pension. We wanted to know how often doctors deliberately write favourable certificates as seen from the patient's point of view, and why doctors do so. MATERIAL AND METHODS: Questionnaire survey to a representative sample of 1605 Norwegian doctors. Doctors who answered yes to the question above gave information about the frequency of such writing of various types of certificates and their reasons for doing so. RESULTS: 1175 (73%) doctors responded. 39% confirmed deliberately writing in favour of their patients. For most types of certificates, a frequency of less than once a year was most common. 55% admitted writing favourably in disability pension certificates more than once a year, 69% so in referrals. The most common reasons given were securing just treatment and quick access to treatment. Many doctors emphasised that by answering yes, they meant that they were indeed writing expert judgments based on correct facts. INTERPRETATION: Medical certificates deliberately written in favour of the patient is not uncommon. This should lead to a critical discussion of the need for such certificates and medical diagnoses as a basis for resource allocation, rather than the tightening of control over the practice of doctors.

Attitude of Health Personnel↗
PubMed2004

Pupillary responses on the visual backward masking task reflect general cognitive ability.

Cognitive processing efficiency requires both an ability to attend to task-relevant stimuli with quickness and accuracy, also while filtering distracting or task-irrelevant stimuli. This study investigated cognitive processing efficiency by using pupillary responses as an index of attentional allocation to relevant target and irrelevant masks on a visual backward masking task. The relationship between attentional allocation on this task and general cognitive ability on the scholastic aptitude test (SAT) was examined in college students (n=67). A principle components analysis of the pupillary response waveform isolated a late component that appeared to index the attentional demands associated with processing masks on the backward masking task. This pupillary response index of wasteful resource allocation to the mask accounted for significant variance in SAT scores over and above that accounted for by socio-economic status and target detection accuracy scores. Consistent with the neural efficiency hypothesis, individuals who allocated more resources to processing irrelevant information performed more poorly on cognitive ability tests.

Adult↗
PubMed1994

The case against using the APACHE system to predict intensive care unit outcome in trauma patients.

The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)

Bias↗
PubMed1996

What is the good of health care?

This paper sets out to discuss what precisely is meant by "benefit" when we talk of the requirement that the health care system concern itself with health gain or with maximising beneficial health care. In particular I argue that in discharging the duty to do what is most beneficial we need to choose between rival conceptions of what is meant by beneficial. One is the patient's conception of benefit and the second is the provider's or funder's conception of benefit. I argue that it is the patient's conception of benefit which is paramount and that if this is followed it commits us to a conception of patient care which must be blind to prognosis in so far as prognosis is thought to bear upon issues of prioritisation or resource allocation.

Altruism↗
PubMed2006

Concepts for risk-based surveillance in the field of veterinary medicine and veterinary public health: review of current approaches.

BACKGROUND: Emerging animal and zoonotic diseases and increasing international trade have resulted in an increased demand for veterinary surveillance systems. However, human and financial resources available to support government veterinary services are becoming more and more limited in many countries world-wide. Intuitively, issues that present higher risks merit higher priority for surveillance resources as investments will yield higher benefit-cost ratios. The rapid rate of acceptance of this core concept of risk-based surveillance has outpaced the development of its theoretical and practical bases. DISCUSSION: The principal objectives of risk-based veterinary surveillance are to identify surveillance needs to protect the health of livestock and consumers, to set priorities, and to allocate resources effectively and efficiently. An important goal is to achieve a higher benefit-cost ratio with existing or reduced resources. We propose to define risk-based surveillance systems as those that apply risk assessment methods in different steps of traditional surveillance design for early detection and management of diseases or hazards. In risk-based designs, public health, economic and trade consequences of diseases play an important role in selection of diseases or hazards. Furthermore, certain strata of the population of interest have a higher probability to be sampled for detection of diseases or hazards. Evaluation of risk-based surveillance systems shall prove that the efficacy of risk-based systems is equal or higher than traditional systems; however, the efficiency (benefit-cost ratio) shall be higher in risk-based surveillance systems. SUMMARY: Risk-based surveillance considerations are useful to support both strategic and operational decision making. This article highlights applications of risk-based surveillance systems in the veterinary field including food safety. Examples are provided for risk-based hazard selection, risk-based selection of sampling strata as well as sample size calculation based on risk considerations.

Animal Diseases↗
PubMed2006

Non-linearity in the cost-effectiveness frontier.

Conventional cost-effectiveness decision rules rely on the assumptions that all health care programmes are divisible and exhibit constant returns to scale for a homogeneous population; hence, the path between adjacent programmes on a cost-effectiveness frontier must be linear. In this paper we build a framework to analyse non-linear 'expansion' paths. We model the impact of two key sources of non-linearity: economies of scale or scope in the production of health care; and prioritisation of patients who are most likely to benefit from more expensive and more effective treatments. We conclude that the expansion path might be linear, convex or concave, depending on the situation. The path might also exhibit vertical discontinuity due to fixed costs or horizontal discontinuity due to indivisibility. The efficiency of resource allocation might be improved by empirical estimation of expansion paths. We discuss the advantages and disadvantages of this approach compared with a standard stratified analysis.

Cost-Benefit Analysis↗
PubMed2003

Patients' needs for nursing care: beyond staffing ratios.

The current focus on staffing ratios as a means to assure appropriate care for patients ignores the very real differences among patients in their needs for nursing care. Implementing a system that identifies these needs provides a more accurate indication of staffing requirements. In addition, storing the raw data from the system at their most basic level provides opportunities for more extensive analyses and informed, data-driven decision-making related to resource allocation, performance improvement, and productivity enhancement.

Benchmarking↗
PubMedDate not supplied

Advance directives: the price of life.

Advance directives support the concepts of patient autonomy and resource allocation. Promotion of advance directives by nurse managers according to the suggested paradigm should be an economic and policy priority.

Advance Directives↗
PubMed2003

Revisiting the decision rule of cost-effectiveness analysis under certainty and uncertainty.

The classical decision rule of cost-effectiveness analysis uses a threshold cost-effectiveness ratio as a cut-off point for resources allocation. One assumption of this decision rule is complete divisibility of health care programs. In this article, we argue that health care programs cannot be completely divisible since individuals are not divisible. Consequently, instead of a linear programming approach, an integer programming approach to budget allocation is suggested. The integer programming framework can be extended to include uncertainty in the analysis. An objective function (expected aggregate effects) is maximised subject to the constraint that the probability of exceeding the budget is limited to an arbitrary level (e.g., 0.05). In case the budget is exceeded, the objective function is penalised in order to account for the opportunity costs of the additional resource requirements.

Budgets↗
PubMed2006

Health care use and costs in the decade after identification of type 1 and type 2 diabetes: a population-based study.

OBJECTIVE: To analyze trends in health care costs in the decade after identification of diabetes, contrasting type 1 and 2 diabetes. RESEARCH DESIGN AND METHODS: The Canadian National Diabetes Surveillance System criteria were applied to administrative databases to identify incident diabetes cases in 1992. Cases were categorized as type 1 or type 2 diabetes based on patterns of drug use. Per capita health care costs (in 2001 Canadian dollars) for five resource categories were estimated according to the type of diabetes, for the year before identification (1991) and 10 years after (1992-2001) identification of the cases. RESULTS: We identified 156 type 1 and 3,469 type 2 incident cases of diabetes, from a population base of approximately 950,000. The mean (+/-SD) age of case subjects at index was 61.2 +/- 16.7 years, and 54% of subjects were male. Overall annual per capita health expenditures rose considerably in the year after identification of diabetes but then stabilized at a lower level for the next 9 years, ranging from $3,800 to $4,400. From 1992 to 2001, diabetic individuals used $137.1 million in health care resources, most of which (96%) was attributable to type 2 diabetes. The average 10-year cost per individual with diabetes was $37,820 ($33,684 per type 1 and $38,006 per type 2 diabetes case; adjusted P = 0.45). CONCLUSIONS: Total health expenditures for diabetes are driven by the much larger prevalence of type 2 compared with type 1 diabetes. Policymakers need to acknowledge and allocate resources for diabetes prevention and management accordingly.

Adult↗
PubMed1998

Ethical considerations in disease management of amyotrophic lateral sclerosis: a cross-cultural, worldwide perspective.

Amyotrophic lateral sclerosis (ALS) is universally fatal. Technological advances have provided a means to impact upon, without radically improving, the natural history of the disease. In addition, we now have the capability of potentially identifying patients who are pre-symptomatic carriers of the rare heritable forms of the disease. These capabilities provide the basis for the numerous ethical dilemmas that face patients, physicians, and agencies responsible for health care expenditures; dilemmas that can only be amplified between cultures. This paper attempts to address some of the major ethical issues germane to the care of ALS patients. It discusses the emergence of autonomy as the reigning principle of medical ethics in the United States and its potential conflict with the ethical dilemma of limited resource allocation. Finally, it attempts to compare and contrast, in an admittedly anecdotal and fragmentary fashion, the perspective of other cultures regarding the care of ALS patients.

Amyotrophic Lateral Sclerosis↗
PubMedDate not supplied

UK budgetary systems and new health-care technologies.

OBJECTIVES: This article outlines the budgetary setting within the UK health-care system. METHODS: It is argued that while prospective budgets can give rise to efficient resource allocation outcomes, this relies on the budget being set at an appropriate level and the accompanying incentive structures being efficient. The organizational structures and the interrelationships are critical. The recent history of UK National Health Service reforms and expenditure is outlined. It is suggested that until recently, although the budget system has the potential to promote efficiency, the aggregate budget allocated to the NHS has probably been too low given public expectations, technology advances, and preferences for health care. RESULTS: The aggregate budget is due to rise considerably over the next 5 years. While some incentive and regulatory provisions will move the budget toward an efficient allocation many microlevel incentive issues remain. CONCLUSION: Whether efficient patterns of health-care allocation emerge remains open to debate, however, because the existing incentive mechanisms are not optimal.

Biomedical Technology↗
PubMed1988

Urbanization trends in Southeast Asia: some issues for policy.

"The apparent Southeast Asian paradox of fairly slow urbanization but rapidly growing urban populations is due to continued high rates of natural increase, especially in rural areas. Southeast Asian countries differ greatly in the nature of their urban hierarchies, and the appropriate policy goals and strategies therefore also differ. In countering growing urban primacy, indirect approaches emphasizing macro-economic and sectoral policies conducive to more dispersed patterns of urban growth have greater potential impact than direct attempts to slow the growth of large city populations. Greater decentralization of power and decision making over resource allocation is also needed."

Asia↗
PubMed1996

The evolution of the intensivist: from health care provider to economic rationalist and ethicist.

In contrast to many open intensive care units (ICUs) in the United State, where "parent" units (sometimes with few intensive care skills) admit and manage their own patients, Australia has closed units in which the intensivist has primary control of patient care while the patient remains in the ICU. This difference is important because in Australia, by virtue of having control of the ICU, the intensivist can be made responsible not only for patients care, but for resource allocation and financial constraint. Australian intensivists are called upon daily to make difficult decisions about who will be admitted, prematurely discharged or transferred from ICUs, and when treatment will be restricted or withdrawn.

Australia↗
PubMedDate not supplied

Mass gathering events: retrospective analysis of patient presentations over seven years.

INTRODUCTION: St John Ambulance Operations Branch Volunteers have been providing first-aid services at the Royal Adelaide Show for 90 years. The project arose from a need to more accurately predict the workload for first-aid providers at mass gathering events. A formal analysis of workload patterns and the determinants of workload had not been performed. HYPOTHESIS: Casualty presentation workload would be predicted by factors including day of the week, weather, and crowd size. METHOD: Collated and analyzed casualty reports over a seven-year period representing >7,000 patients who presented for first-aid assistance for that period (63 show days) were reviewed retrospectively. RESULTS: Casualty presentations correlated significantly with crowd size, maximum daily temperature, humidity, and day of the week. Patient presentation rate had heterogeneous determinants. The most frequent presentation was minor medical problems with Wednesdays attracting higher casualty presentations and more major medical categories. CONCLUSION: Individual event analysis is a useful mechanism to assist in determining resource allocation at mass gathering events providing an evidence base upon which to make decisions about future needs. Subsequent analysis of other events will assist in supporting accurate predictor models.

Anniversaries and Special Events↗