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PubMed2002

Views of Directors of Public Health about NICE Appraisal Guidance: results of a postal survey. National Institute for Clinical Excellence.

BACKGROUND: We aimed to determine the views of Directors of Public Health about the Health Technology Appraisal Programme of the National Institute for Clinical Excellence (NICE) before the move to strategic health authorities and primary care trusts in April 2002. METHOD: In December 2001 we sent a questionnaire asking about the work programme, products, decision-making, general approach, resource allocation and success of NICE to all Directors of Public Health in England and Wales. Ninety-two of 100 responded. RESULTS: Three-quarters or more agreed that NICE has covered a number of priority and controversial areas, produced good-quality health technology appraisals, well-presented reports and readable guidance in a consistent format, that it has raised the profile of clinical effectiveness, provided a focus for debate about health technology, and succeeded in making the National Health Service (NHS) set aside resources for approved technologies. A similar proportion, however, also agreed that guidance was not timely, did not address 'whole systems' and made some disappointing recommendations, and that decision-making was not influenced enough by the needs of the NHS. They considered that NICE did not address implementation, decide between competing technologies or help the service prioritization debate, and that guidance sent unrealistic signals about affordability to patients and politicians and caused difficulty for the implementation of other technologies locally. CONCLUSIONS: A majority of Directors are positive about NICE's role of providing high-quality appraisal and central guidance but negative about its influence on local priority setting. Major concerns remain about the affordability of competing demands, whether this is NICE's responsibility or not.

Administrative Personnel↗
PubMed2005

Economic evaluation of medical technologies.

Innovation in medical science is progressing at a rapid pace. As a result, new medical technologies that offer to improve upon or completely replace existing alternatives are continually appearing. These technologies--which include pharmaceuticals, devices, equipment, supplies, medical and surgical procedures, and administrative and support systems--are changing the way medicine can be practiced and delivered, forcing healthcare providers and policymakers to consistently evaluate and adapt to new treatment options. Meanwhile, society is becoming more demanding of new medical technologies. Emerging medical technology, however, has been viewed as a significant factor in increasing the cost of healthcare. The abundance of new medical alternatives, combined with scarcity of resources, has led to priority setting, rationing and the need for more technology management and assessment. Economic evaluation of medical technologies is a system of analysis used to formally compare the costs and consequences of alternative healthcare interventions. EEMT can be used by many healthcare entities, including national policymakers, manufacturers, payers and providers, as a tool to aid in resource allocation decisions. This paper discusses the four current popular methodologies for EEMT (cost-minimization, cost-benefit, cost-effectiveness and cost-utility), and describes the industry environment that has shaped their development.

Cost-Benefit Analysis↗
PubMed2005

Is a family equal to the sum of its parts? Estimating family-level well-being for cost-effectiveness analysis.

Cost-effectiveness (CEA) analysis of health interventions focuses primarily on individual-level costs and benefits. However, health interventions intended for individuals often have implications for other members of an individual's family and the overall functioning of the family. While researchers have assessed the effects of health interventions on multiple family members, CEA has not routinely incorporated measures of effectiveness or costs from multiple family members. We could imagine, however, that CEA might over- or under-estimate the effects of health interventions if they are limited to individuals targeted by the intervention. Family-level CEA would consider the well-being of and costs borne by multiple family members in response to an individual-level intervention, and potentially lead to more appropriate resource allocation. Using the health plan as a working frame of reference, we explore conceptual issues related to estimating effectiveness at the level of the family for use in CEA.

Cost of Illness↗
PubMed1988

Generational equity and social insurance.

In recent years, critics have argued that, when inter-generational transfer programs such as Medicare are judged by the standard of "generational equity", these programs are seen to be unfair. It is argued that, under a pay-as-you-go system, future generations are committed to burdens without their consent; that claims are not contractually guaranteed; that early entrants reap windfalls gains; that successive cohorts are tempted to provide insupportably high benefit levels; and, finally, that fluctuations leave future generations at unacceptable risk. Attempts have been made to defend social insurance programs by means of a "lifespan prudential model" of age-group resource allocation, but this defense does not adequately take account of uncertainties and inequities faced by historical birth cohorts. A deeper defense must acknowledge an element of risk-sharing and solidarity while trying to limit inequities within reasonable bounds.

Aged↗
PubMed2004

Prevalence of BRCA1 mutation carriers among U.S. non-Hispanic Whites.

Data from several countries indicate that 1% to 2% of Ashkenazi Jews carry a pathogenic ancestral mutation of the tumor suppressor gene BRCA1. However, the prevalence of BRCA1 mutations among non-Ashkenazi Whites is uncertain. We estimated mutation carrier prevalence in U.S. non-Hispanic Whites, specific for Ashkenazi status, using data from two population-based series of San Francisco Bay Area patients with invasive cancers of the breast or ovary, and data on breast and ovarian cancer risks in Ashkenazi and non-Ashkenazi carriers. Assuming that 90% of the BRCA1 mutations were detected, we estimate a carrier prevalence of 0.24% (95% confidence interval, 0.15-0.39%) in non-Ashkenazi Whites, and 1.2% (95% confidence interval, 0.5-2.6%) in Ashkenazim. When combined with U.S. White census counts, these prevalence estimates suggest that approximately 550,513 U.S. Whites (506,206 non-Ashkenazim and 44,307 Ashkenazim) carry germ line BRCA1 mutations. These estimates may be useful in guiding resource allocation for genetic testing and genetic counseling and in planning preventive interventions.

Adult↗
PubMed1990

Current trends in biomedical ethics in the United States.

Enormous growth of medical activities and issues in the 1960s and 1970s stimulated birth of the field of contemporary biomedical ethics. Nevertheless, when one examines recent trends within the field in the United States, one is struck with how many significant transformations and developments have occurred since that time. This presentation examines recent developments in five areas--those of patient rights and autonomy, termination of life, manipulation of Nature, health care resource allocation, and decision-making by the general public. The author also notes that although bioethical issues have become politicized as major interest groups and the general public have become increasingly involved, the quest for consensus remains a central one for health care ethics in the United States.

Bioethical Issues↗
PubMed1986

The ethical dilemmas of a rural physician.

Physicians in rural settings confront many of the same ethical dilemmas as their urban counterparts: confidentiality, quality-of-life decisions, resource allocation, and their moral responsibility for bettering the life of the community. However, the courses of action they choose as morally justifiable are influenced by distance from other professional facilities, the interrelationship of private and professional roles in a small community, and the non-specialized orientation of their practices.

Confidentiality↗
PubMedDate not supplied

[Community participation and social control in the health system].

In Colombia, the 1991 Constitution established the obligation of promoting social participation. However, the discussion regarding the significance and scope of social participation is far from being over with the promulgation of the Constitution since social participation has a high political component, i.e., social participation requires the transfer of a part of power to sectors previously excluded from decision taking. As long as the State has conceived the market strategy as the best way to allocate resources and the receptors of social policy are considered as consumers, the challenge is to establish a balance between supply and demand in order to guarantee efficiency and efficacy in the application of resources and transparency in the public administration. Thus, the community of users has the mission of monitoring the correct allocation of State resources. Upon evaluating some of the results of the application of this strategy of social participation in health, three features can be highlighted: there are important advances in the promotion of social participation but not in social control; social control is dispersed and atomized, and participation as institutional policy is weak. Regarding the first aspect, it can be concluded that there has been a favorable response of the municipalities to the obligation of promoting the organizational forms of the community as far as health is concerned. When the actions carried out for social control are taken into account, the outlook varies. The convoking capacity of the institutions of the system to community organizations is considerably low, as well as the discussion of the reports presented by such organizations. On the other hand, the lack of communication between the different instances involved in both promotion of participation and social control became evident, situation which reflects the presence of relationships of bilateral nature, i.e., only the most direct interlocutor is known.

Colombia↗
PubMed2004

Survey of specialized tertiary care facilities for adults with congenital heart disease.

BACKGROUND: Specialized tertiary care facilities developed in response to the increasing numbers of adults with congenital heart disease (CHD). Because this patient population comprises a relatively new area of specialized cardiovascular interest, the first facilities necessarily evolved without preexisting guidelines or interaction. OBJECTIVES: To characterize the major features of the six original and largest tertiary adults CHD facilities. METHODS: Written questionnaire sent to six participating facilities in North America and Europe. Information was analyzed centrally. RESULTS: All but one facilities was established over 20 years ago, and each cares for over 1500 patients. Hospital admissions ranged from 100 to 660 patients/unit/year. Of the total number of registered patients, 52-81% had undergone one or more reparative surgeries. Reoperations constituted 25-80% of the 50-170 operations/unit/year. Overall mean surgical mortality was 1.9%/year. Inpatient and outpatient care was provided in adult (n = 4) or both adult and pediatric (n = 2) settings. All six facilities enjoyed close collaboration between adult and pediatric cardiologists, cardiac surgeons, nurse specialists and cardiac and non-cardiac consultants. Training and research were pivotal activities. CONCLUSIONS: Provision of comprehensive care by multidisciplinary teams including adult and pediatric cardiologists, cardiac surgeons, specialized nurses and other cardiac and non-cardiac consultants was the unifying feature for all six tertiary care facilities reported here. There were minor differences among them based on available resources, local expertise and national health care policies. There appears to be a significant shortfall in tertiary care provision for the adult with CHD that requires further planning and resource allocation. These data may be useful for new and evolving adult CHD services.

Adolescent↗
PubMed1997

The role of reader age and focus of attention in creating situation models from narratives.

We examined adult age differences in the mental representation of situations and how readers update this representation during narrative comprehension. Older and younger adults memorized a building layout and then read narratives about a protagonist's actions in this building. The narratives contained critical sentences that described the protagonist moving from one room (the "source room") into another (the "goal room"), through an unmentioned path room. Each critical sentence was followed by a target sentence referring to an object in one of these rooms. Half of the target sentences explicitly mentioned the room containing this object and half did not. Reading time increased when the target object was more distant from the protagonist and when the room containing the object was not mentioned, suggesting that readers tracked the protagonist's location in the layout and allocated resources in order to maintain coherence in the situation model. Older adults' reading times differentially slowed with distance, and older readers who more accurately understood the narrative differentially slowed when the location of the target object was not mentioned. Finally, the more accurate readers (older and younger) slowed primarily when updating was most difficult (i.e., both when the room containing the object was not mentioned and for more distant objects). While these findings reveal qualitative similarity in how older and younger readers update spatially organized situation models, they also suggest that older readers must sometimes allocate more resources to this updating process in order to maintain comprehension.

Adult↗
PubMed1993

Ethics consultants' recommendations for life-prolonging treatment of patients in a persistent vegetative state.

OBJECTIVE--Surprisingly little is known about the content of ethics consultants' recommendations. We chose to study this issue using hypothetical persistent vegetative state (PVS) cases. We addressed four questions: What recommendations do ethics consultants give regarding life-prolonging treatment (LPT) in PVS cases? To what degree is there consensus? What factors influence recommendations? Do recommendations conform to established guidelines? DESIGN--Questionnaire survey. Our questionnaire asked subjects what they would recommend for seven hypothetical vignettes involving a PVS patient that varied with respect to advance directives and family wishes. We also questioned subjects about demographic characteristics, ethics consultation experience, and personal preference for LPT in PVS. SUBJECTS--Attendees at an annual meeting of the Society for Bioethics Consultation (n = 154). RESULTS--The response rate was 77%. Eighty-one percent of respondents were ethics committee members and 62% were ethics consultants. There was general agreement among respondents for only one of seven vignettes: in the case of a PVS patient whose advance directive and family agree that LPT be stopped, 93% recommended stopping all LPT. Responses to other vignettes varied considerably. Although patient wishes were an important factor influencing recommendations, none of the respondents adhered invariably to the patient's advance directive. Recommendations were also influenced by family wishes, resource allocation considerations, legal constraints, and personal preference for LPT in PVS. Guidelines we examined were generally too equivocal to be useful for evaluating ethics consultants' recommendations. CONCLUSIONS--The finding of wide variability in ethics consultants' recommendations suggests a need to clarify standards for ethics consultation.

Coma↗
PubMed2003

Analysis model for planning chemical dependence treatment systems.

Statewide needs assessments commonly generate a single estimate of the number of persons needing chemical dependence treatment. The present analysis utilizes help-seeking behavior models and patient placement concepts to break a single statewide need estimate into operational units of services and costs that can be used for planning and resource allocation. The analyses are presented as allocation models for placements, service populations, service capacities, and costs. The guide was tested using state data for a target year and the results were compared to actual treatment admissions, which revealed a lack of convergence. Only 9% of persons were estimated to need intensive residential treatment whereas actual admissions to intensive residential treatment accounted for 29% of all admissions. The disparities may be accounted for by sampling bias of the needs estimate and by the likelihood that persons with more severe problems may be overrepresented when only a small proportion of treatment need is being met. These findings suggest that if resources become available to narrow the treatment gap, a larger proportion of outpatient services and less intensive services may be appropriate for the expanded clientele.

Health Planning↗
PubMedDate not supplied

Tapping health care resources: a comparison of US and UK strategies.

The United Kingdom and the United States are both facing dramatic changes in health care delivery and resource allocation, brought about by advanced technology, limited financial (and in some cases human) resources and conflicting values regarding the right to health care. The differences and similarities of their health care systems provide a favourable research environment for comparing how the two countries acquire and allocate their respective health care resources. For the purpose of such a comparative study, two sites were selected, the London region of Central Thames and the US city of Energytown (only the names are fictitious). Central Thames is representative of an English region in size, administrative structure and health services; Energytown is representative of an oil city in the US Midwest. National policy, reductions in health care funds and size make the areas amenable to a comparative study.

Health Policy↗
PubMed1992

American College of Physicians Ethics Manual. Third edition.

Medicine, law, and social values are not static and must be re-examined periodically. This edition of the ACP Ethics Manual covers emerging issues in medical ethics and revisits some old issues. The overview of the evolution of medical ethics, which appeared in previous editions of the Manual, has been eliminated to allow more space for the consideration of today's ethical dilemmas. Other changes include a revised chapter on end-of-life care, discussion of physician-assisted suicide, revised sections on conflicts of interest and on medical risk to the physician and patient, given developments in human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS), and discussion of sexual contact between physician and patient. A statement on disclosure of errors and a section on care of the physician's family have also been added. The sections on confidential information told by a patient's family or friend to the physician; on physician-pharmaceutical industry relations; on physicians in training; and on the impaired physician have been expanded. Sections on advertising, peer review, and resource allocation have been revised. The literature of biomedical ethics expands at a rate that does not allow a bibliography to remain current, so an exhaustive list of references or suggested readings is not included in this manual. Instead, only cited references are listed.

Codes of Ethics↗
PubMed2003

Societal services after traumatic spinal cord injury in Sweden.

OBJECTIVE: Societal services after traumatic spinal cord injury in Sweden were investigated, including self-rated levels of satisfaction with the application process and resource allocation. DESIGN: Survey of an incidence population. SUBJECTS: Thirty-four persons of a total regional incidence population (n = 48) with traumatic spinal cord injury. METHODS: Structured interviews using a standardized questionnaire. RESULTS: About 25 separate services were identified being available for persons with traumatic spinal cord injury. The average number of applications per person was 5 (range 0-11). The most common service was "transportation service". Of the applications, 17% were partially or totally rejected. Most subjects received information about available services from a social worker. For 13 available services at least 1 subject claimed ignorance about its existence. CONCLUSIONS: In Sweden, significant resources are allocated for allowing independence and financial compensation for individuals with traumatic spinal cord injury. However, this support system sometimes also results in frustration and disappointment. Insufficient information and co-ordination are reported as weaknesses. The persons' efforts to acquire knowledge of how the system works take time which could be better used for rehabilitation and full integration into the community.

Adolescent↗
PubMed2004

Amplifying nursing's voice through a staff-management partnership.

Recommendations to decrease the nursing shortage often identify the need to strengthen nurses' autonomy and control in hospitals but do not describe specific mechanisms to accomplish this goal. The Nurse Practices Committee provides a forum for staff nurses and nurse executives at Robert Wood Johnson University Hospital to jointly make decisions about resource allocation. Committee members agree that this work has strengthened relationships by fostering mutual understanding, respect, and trust. As a result, nursing management and staff partners can advocate for patients and nurses with a single, more powerful voice.

Decision Making, Organizational↗
PubMed2002

Looking at the forest instead of counting the trees: an alternative method for measuring faculty's clinical education efforts.

PURPOSE: To present an alternative approach to mission-based management (MBM) for assessing the clinical teaching efforts of the faculty in the third and fourth years of medical students' education. METHOD: In fiscal years 2000 and 2001, interviews were conducted with department chairs and faculty members with major responsibilities in education at the University of Maryland School of Medicine. Using a standard worksheet, each rotation was categorized according to the amounts of time students spent in five teaching modes. After each department described its rotation and maximum teaching time, the department team and the MBM team negotiated the final credit received for its course. This final determination of departmental clinical teaching was used in subsequent calculations. Adjustments were made to the department clinical education time based on the teaching mode. Groups of medical students were surveyed to determine the relative value of each teaching mode. These relative values were then used to modify the clinical education times credited to the department. The last step was to distribute the effort of the faculty between clinical and educational missions. RESULTS: The data analysis showed approximately 57,000 credited faculty hours in one year for direct education of medical students in each curriculum year. These hours equal the annual workload of 28 full-time faculty members. CONCLUSIONS: A powerful use of MBM data is to move from thinking about resource allocation to thinking about the effective management of a complex organization with interlaced missions. Reliable data on faculty's contributions to medical students' education across departments enhances other MBM information and contributes to a picture of the dynamic interconnectedness of missions and departments.

Education, Medical, Undergraduate↗
PubMed1995

Patients' views of priority setting in health care: an interview survey in one practice.

OBJECTIVES: To explore the assumptions underlying consumers' responses to questions of resource priorities in the NHS. DESIGN: Qualitative analysis of semi-structured interviews with a heterogeneous sample of 16 patients drawn from a general practice. RESULTS: Interviewees were not persuaded that they had a legitimate role to play in the prioritisation of services. They supported the principle of equity and were reluctant to use their own personal needs as a basis for resource allocation; instead they argued from what they perceived to be the needs of others. CONCLUSIONS: Paradoxically, surveys of consumers' views on health care priorities probably do not elicit the personal ideas of respondents but tap into a more general ideological position closer to an earlier collectivist notion of health care.

Adult↗