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PubMed1983

In vitro fertilisation: the major issues.

In vitro fertilisation is now an established technique for treating some forms of infertility, yet it remains ethically controversial. New developments, such as embryo donation and embryo freezing, have led to further discussion. We briefly discuss the ethical aspects of IVF, focusing on the issues of resource allocation, the 'unnaturalness' of the procedure, the moral status of the embryo, surrogate motherhood, and restrictions on access to IVF. We argue that, on the whole, IVF is an ethically justifiable method of assisting infertile couples.

Adoption↗

PubMed2003

The efficacy of pre-operative home visits for total hip replacement clients.

BACKGROUND: There is increasing realization among health care administrative decision makers and service providers that we must measure the true value of expensive services by demonstrating the achievement of identified goals. PURPOSE: The objective of this study was to determine whether clients who received the home-based intervention for a hip arthroplasty would result in a more timely discharge home from hospital. METHOD: Two hundred and eight clients receiving a total hip replacement at two acute care hospitals comprised the sample. One hospital included the more costly home-based pre-operative teaching by an occupational therapist as part of its protocol while the other provided comparative occupational therapy intervention within its hospital based pre-admission clinic. Discharge disposition and length of hospital stay were measured. RESULTS: Though no significant difference in either of these outcomes was found, a number of issues were raised indicating the complexity of resource allocation to this client population and the importance of the qualitative dimensions of care. PRACTICE IMPLICATIONS: The location for pre-operative teaching for total hip replacements was not found to impact the length of hospital stay nor whether clients are discharged directly home.

Arthroplasty, Replacement, Hip↗

PubMed2003

Developing a linked administrative database of health service utilisation by the aging population of metropolitan Perth.

The increasing use of health services by the older population has placed significant stresses on the health system of Western Australia. This is a report of the development of a linked administrative database of health resource utilisation by the aged population of metropolitan Perth. Hospital administrative databases linked to clinical or administrative databases of other health providers are reviewed. Length of stay data is linked to aged care assessments, referrals to nursing homes and community services. The linked databases approach allows the study of resource allocation and can pinpoint systemic stress in aged care. It is a tool for reducing the duplication of services, the pressure on beds in health institutions, and cost by improving efficiencies.

Aged↗

PubMed2003

Simulation-based medical education: an ethical imperative.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Computer Simulation↗

PubMed2003

Allocating health care resources when people are risk averse with respect to life time.

The criterion of cost-effectiveness in health management may be given a welfare-theoretical justification if people are risk neutral with respect to life years. With risk aversion, the optimal allocation of health expenditures changes: Compared to the cost-effective allocation, more resources should be allocated to health conditions for which the expected outcomes even after treatment are worse than average. The consequences of medical interventions are usually not known with certainty. Given this type of uncertainty, simple application of cost-effectiveness analysis would recommend maximization of expected health benefits given the health budget. We show that when people are risk averse with respect to the number of life years they live, the uncertainty associated with different types of interventions should play a role in allocating the health budget.

Cost-Benefit Analysis↗

PubMed1996

Access to adult liver transplantation in Canada: a survey and ethical analysis.

OBJECTIVES: To describe the substantive and procedural criteria used for placing patients on the waiting list for liver transplantation and for allocating available livers to patients on the waiting list; to identify principal decision-makers and the main factors limiting liver transplantation in Canada; and to examine how closely cadaveric liver allocation resembles theoretic models of source allocation. DESIGN: Mailed survey. PARTICIPANTS: Medical directors of all seven Canadian adult liver transplantation centres, or their designates. Six of the questionnaires were completed. OUTCOME MEASURES: Relative importance of substantive and procedural criteria used to place patients in the waiting list for liver transplantation and to allocate available livers. Identification of principal decision-makers and main limiting factors to adult liver transplantation. RESULTS: Alcoholism, drug addiction, HIV positivity, primary liver cancer, noncompliance and hepatitis B were the most important criteria that had a negative influence on decisions to place patients on the waiting list for liver transplantation. Severity of disease and urgency were the most important criteria used for selecting patients on the waiting list for transplantation. Criteria that were inconsistent across the centres included social support (for deciding who is placed on the waiting list) and length of time on the waiting list (for deciding who is selected from the list). Although a variety of people were reported as being involved in these decisions, virtually all were reported to be health to be health care professionals. Thirty-seven patients died while waiting for liver transplantation in 1991; the scarcity of cadaveric livers was the main limiting factor. CONCLUSIONS: Criteria for resource allocation decisions regarding liver transplantation are generally consistent among the centres across Canada, although some important inconsistencies remain. Because patients die while on the waiting list and because the primary limiting factor is organ supply, increased organ acquisition efforts are needed.

Adult↗

PubMedDate not supplied

Quality time: how parents' schooling affects child health through its interaction with childcare time in Bangladesh.

A child health production function is presented with the key feature being an interaction term between a caregiver's schooling and their exposure time to the child. The production function is estimated using a 2SLS fixed effects model with lagged childcare time, resource allocation and child health as instruments for the first differences of these same endogenous variables. The 1978 Intrafamily Food Distribution and Feeding Practices Survey dataset from Bangladesh is used together with census data. The production function estimates indicate that part of the salutary effects of parental education on child health require that the child actually be exposed to the educated parent. Given the demographic makeup of the study sample and the assumption that age education and gender completely account for productivity, teenage brothers and fathers would have the highest marginal productivity for child health and mothers and grandmothers the least. If economic opportunity draws mothers away from childcare, the presence of other household members with higher schooling levels offers the potential for an improvement in the overall quality of childcare time. In the present study the households failed to set the marginal labour product of child health for each of the caregivers equal. Thus, the quality of childcare may not be the household's sole concern in determining time allocation.

Adolescent↗

PubMed2003

An inquiry into the different perspectives that can be used when eliciting preferences in health.

There are a number of perspectives that an individual could be asked to adopt in studies designed to elicit preferences for use in informing resource allocation decisions in health care. This paper develops a conceptual framework that clearly distinguishes between six different perspectives. It is argued that the appropriate perspective to use depends on normative considerations and the particular policy context to which it will be applied. We suggest a future research agenda that explicitly addresses these considerations and which involves direct empirical investigation into the effect of perspective on preferences.

Decision Making↗

PubMed1992

Prioritizing Oregon's hospital resources. An example based on variations in discretionary medical utilization.

OBJECTIVE: To provide an alternative to Oregon's treatment-specific approach to rationing, we propose a prioritization based on the local hospital resources invested in discretionary medical admissions. DESIGN: We used 1988 Oregon hospital discharge data to determine age- and sex-adjusted per-capita rates of inpatient days for discretionary medical admissions (for high-variation medical conditions) in each of 33 hospital service areas. Potential ceiling rates were defined based on prevailing utilization rates for discretionary medical admissions in each hospital service area. Savings were calculated under the assumption that resources allocated for inpatient treatment of these conditions in areas that exceed the ceiling rates were reduced accordingly. SETTING: Nonfederal, acute-care hospitals used by Oregon residents. STUDY POPULATION: Oregon residents. MAIN OUTCOME MEASURES: Savings were defined in terms of patient days, hospital beds, hospital charges, and average costs. RESULTS: Among the 16 largest hospital service areas, patient-day rates for discretionary medical admissions ranged from 188 to 335 patient days per thousand. Potential savings from applying different ceiling rates ranged from $0.4 million to $94.7 million per year. If the rate in the state capital (Salem) were used as the ceiling (218 days per thousand), then 238 beds could be closed in 20 hospital service areas, for an estimated cost savings of $47.3 million. CONCLUSIONS: Hospital resources invested in discretionary admissions in high-rate areas represent an important potential source of funds for reallocation to meet other defined health care needs. Setting limits based on units of health care supply (eg, beds, capital equipment, and physicians) should be considered as an option for resource reallocation within health care.

Bed Occupancy↗

PubMed2003

[Fair hospital comparisons -- does the method contracted in Germany enable unbiased results?].

AIM: To evaluate the method for comparison of average length of stay in hospitals as defined in a contract between German health insurance companies and the "Deutsche Krankenhausgesellschaft" (German Hospital Association). METHOD: Simulation study executing the algorithm agreed upon in different scenarios, which varied the number of hospitals to be compared, the dispersion of diagnostic specialization over hospitals, and the distribution of hospitals' sizes. Scenarios were constructed to realistically reflect the situation in German inpatient treatment of mentally ill patients. RESULTS: By fixing casemix adjustments only on diagnoses of patients and by doing so aggregated on the level of hospitals, the method for comparison yielded artificial differences between hospitals even in a situation where each patient is treated with exactly the same amount of resource allocation (given the individual needs defined for all scenarios). Results of artificial differences were heavily biased against or in favour of the reference hospitals according to the specific condition of the scenario parameters. CONCLUSION: The contracted method is not capable of achieving fair hospital comparisons, at least not for psychiatric hospitals.

Algorithms↗

PubMed2002

Priority-setting ethics in public health.

Unlike the well-developed system of ethical priority-setting that physicians and bioethicists have developed in the field of organ transplantation, public health lacks a standardized and publicly recognized system for making ethical resource allocation decisions. Such a system would be useful for the purpose of countering prejudice-based arguments that tend to hinder the progress of public health programs aimed at marginalized groups. By examining organ transplantation priority-setting criteria as they relate to public health issues, this article seeks to stimulate debate about the varieties of criteria that should and should not be used in public health decision-making.

Acquired Immunodeficiency Syndrome↗

PubMed2003

[Pain management: health economics and quality of life considerations].

Pain represents a major clinical, social and economic problem, with estimates of its prevalence ranging from 8% to more than 60%, depending on the population. The impact of pain on economies is enormous, with the cost of back pain alone equivalent to more than one-fifth of one country's total health expenditure and 1.5% of its annual gross domestic product, while in another it represents three times the total cost of all types of cancer. However, decision makers have tended to concentrate their attention on one very minor component of the cost burden, namely prescription costs, which, in the case of back pain, represent 1% of the total cost burden. In addition to its economic impact, chronic pain is probably one of the diseases with the greatest negative impact on quality of life. For example, the quality of life for those with migraine had been shown to be at best equal to that for people with arthritis, asthma, diabetes mellitus or depression. The burden that pain imposes on individuals and the enormous costs that society has to bear as a result clearly demonstrate the need for collective thinking in the decision-making process. A broad, strategic perspective--based on evidence relating to effectiveness (including tolerability), efficiency and equity--is required in determining issues relating to the provision of services and resource allocation. In this regard, it is clear that paracetamol (acetaminophen) is effective in securing an analgesic effect; it has a good tolerability profile and is relatively cheap, in terms of both drug acquisition costs and its overall cost profile. Pain management strategies based on collective thinking should therefore place great reliance on paracetamol as an initial therapy in maximising pain relief and minimising cost and the impact of adverse effects.

Acetaminophen↗

PubMed2005

Risk aversion and uncertainty in cost-effectiveness analysis: the expected-utility, moment-generating function approach.

The availability of patient-level data from clinical trials has spurred a lot of interest in developing methods for quantifying and presenting uncertainty in cost-effectiveness analysis (CEA). Although the majority has focused on developing methods for using sample data to estimate a confidence interval for an incremental cost-effectiveness ratio (ICER), a small strand of the literature has emphasized the importance of incorporating risk preferences and the trade-off between the mean and the variance of returns to investment in health and medicine (mean-variance analysis). This paper shows how the exponential utility-moment-generating function approach is a natural extension to this branch of the literature for modelling choices from healthcare interventions with uncertain costs and effects. The paper assumes an exponential utility function, which implies constant absolute risk aversion, and is based on the fact that the expected value of this function results in a convenient expression that depends only on the moment-generating function of the random variables. The mean-variance approach is shown to be a special case of this more general framework. The paper characterizes the solution to the resource allocation problem using standard optimization techniques and derives the summary measure researchers need to estimate for each programme, when the assumption of risk neutrality does not hold, and compares it to the standard incremental cost-effectiveness ratio. The importance of choosing the correct distribution of costs and effects and the issues related to estimation of the parameters of the distribution are also discussed. An empirical example to illustrate the methods and concepts is provided.

Cost-Benefit Analysis↗

PubMed2004

Hidden curriculum in continuing medical education.

In developing curricula for undergraduate and graduate medical education, educators have become increasingly aware of an interweaving of the formal, informal, and hidden curricula and their influences on the outcomes of teaching and learning. But, to date, there is little in the literature about the hidden curriculum of medical practice, which takes place after graduation and certification. This article initiates that discussion with influences of the hidden curriculum on the actions physicians take or do not take in caring for patients. Hafferty's framework of institutional policies, evaluation activities, resource-allocation decisions, and institutional slang, along with our knowledge of health services research and the continuing medical education (CME) research literature, suggests that there is a hidden and powerful curriculum that affects physician performance. Determining whether the hidden curriculum conflicts with the messages that we are delivering through formal CME (courses, clinical practice guidelines, peer review journals) may contribute to improving our impact on physician performance.

Curriculum↗

PubMed1992

AIDS: what does economics have to offer?

AIDS is rapidly becoming a major health problem in developing countries. Limited empirical information is available about the impact of AIDS on the household, the community, the health sector and the broader economy. Special problems exist in estimating the direct economic costs of AIDS in developing countries, including large out-of-pocket expenditures on health care and shortages of drugs and supplies; the difficulties of valuing resources used in caring for people with AIDS; and the lack of treatment alternatives. The calculation of indirect costs is complicated by difficulties in calculating the value of non-market production and international comparisons of the value of healthy life years lost may be erroneous, due to the higher level of average wages in developed countries. Existing evidence on the impact of AIDS at the household, community, sectoral and macroeconomic level is reviewed. Special attention is given to the impact of AIDS on the health sector and the resource allocation decisions which are made at this level. A policy-relevant research strategy would include addressing the particular information needs of the health sector, as well as studies which can help to inform government policy to mitigate the impact of AIDS at the household, community, sectoral and macroeconomic levels.

Acquired Immunodeficiency Syndrome↗

PubMed1993

The cost of the district hospital: a case study in Malawi.

Described in an analysis of the cost to the Ministry of Health of providing district health services in Malawi, with particular emphasis on the district hospital. District resource allocation patterns were assessed by carefully disaggregating district costs by level of care and hospital department. A strikingly low proportion of district recurrent costs was absorbed by salaries and wages (27-39%, depending on the district) and a surprisingly high proportion by medical supplies (24-37%). The most expensive cost centre in the hospital was the pharmacy. A total of 27-39% of total recurrent costs were spent outside the hospital and 61-73% on hospital services. The secondary care services absorbed 40-58% of district recurrent costs. Unit costs by hospital department varied considerably by district, with one hospital being consistently the most expensive and another the cheapest. A total of 3-10 new outpatients could be treated for the average cost of 1 inpatient-day, while 34-55 could be treated for the average cost of 1 inpatient. The efficiency of hospital operations, the scope for redistributing resources districtwide, and the costing methodology are discussed.

Capital Expenditures↗

PubMed1995

Health policy approaches to measuring and valuing human life: conceptual and ethical issues.

To achieve more cost-effective and equitable use of health resources, improved methods for defining disease burdens and for guiding resource allocations are needed by health care decision makers. Three approaches are discussed that use indicators that combine losses due to disability with losses due to premature mortality as a measure of disease burden. These indicators can also serve as outcome measures for health status in economic analyses. However, their use as tools for measuring and valuing human life raises important questions concerning the measurement of mortality and the multidimensions of morbidity; valuing of life, particularly regarding weighting productivity, dependency, age, and time-preference factors; and conflicts between equity and efficiency that arise in allocation decisions. Further refinement of these tools is needed to (1) incorporate national and local values into weighting; (2) elaborate methods for disaggregating calculations to assess local disease patterns and intervention packages; and (3) develop guidelines for estimating marginal effects and costs of interventions. Of utmost importance are methods that ensure equity while achieving reasonable efficiency.

Cost of Illness↗

PubMed1991

The role of public values in setting health care priorities.

Public values must play a substantial role in any attempt to deal with the health care resource allocation problem. This article examines how preferences for the health outcomes of care (e.g. improved or worsened physical suffering) can provide a coherent basis upon which set explicit health care priorities. Preferences for health outcomes could be mapped onto information concerning the outcomes expected from the specific health services when used for particular clinical conditions. These 'preference-weighted' outcomes would determine the relative priority given to health services for each specific condition. Generic outcome measures would be used in order to permit comparison of benefits and harms across different services. It is argued herein that allocation rules cannot be based on individual patients' preferences. Instead, average population preferences should be used to evaluate the relative importance of services--as occurs in other insurance contexts--despite theoretical concerns about the aggregation of preferences. Patients' preferences might also be estimated by reference to relevant demographic factors, but only if population subgroups are identified with relatively homogeneous preference patterns and if the use of such subgroups is deemed socially acceptable. Concerns about stereotyping and discrimination might limit the tractability of this approach.

Biomedical Research↗