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PubMed1992

Ambulatory care pharmacy services: the incomplete agenda.

OBJECTIVE: To review studies that document the impact of clinical pharmacy services in ambulatory care settings and to propose standards of practice and resource allocation needs in ambulatory care. DATA SOURCES: English-language literature from 1970 through 1991 was reviewed and the representative literature is described. STUDY SELECTION: Studies were selected that examined the impact of clinical pharmacy services on patient outcomes and costs. Studies that evaluated pharmacist consultations by blind peer-review panels were also evaluated. DATA EXTRACTION: Trials were assessed based on their methodologies and ability to assess the value of clinical pharmacy services on patient outcomes. DATA SYNTHESIS: Numerous studies from the past 20 years are described illustrating the impact that ambulatory care pharmacy practitioners have made on patient care. These studies demonstrate that clinical pharmacists in ambulatory care not only serve as consultants on pharmacotherapy issues, but also can improve the quality of care for individual patients. CONCLUSIONS: Based on the studies cited and the needs of ambulatory patients, this article highlights the authors' views on what the standards of practice should be for ambulatory care practitioners and where resources should be allocated as ambulatory programs are expanded.

Ambulatory Care↗

PubMed2003

Activity-based costing: a practical model for cost calculation in radiotherapy.

PURPOSE: The activity-based costing method was used to compute radiotherapy costs. This report describes the model developed, the calculated costs, and possible applications for the Leuven radiotherapy department. METHODS AND MATERIALS: Activity-based costing is an advanced cost calculation technique that allocates resource costs to products based on activity consumption. In the Leuven model, a complex allocation principle with a large diversity of cost drivers was avoided by introducing an extra allocation step between activity groups and activities. A straightforward principle of time consumption, weighed by some factors of treatment complexity, was used. The model was developed in an iterative way, progressively defining the constituting components (costs, activities, products, and cost drivers). RESULTS: Radiotherapy costs are predominantly determined by personnel and equipment cost. Treatment-related activities consume the greatest proportion of the resource costs, with treatment delivery the most important component. This translates into products that have a prolonged total or daily treatment time being the most costly. The model was also used to illustrate the impact of changes in resource costs and in practice patterns. CONCLUSION: The presented activity-based costing model is a practical tool to evaluate the actual cost structure of a radiotherapy department and to evaluate possible resource or practice changes.

Accounting↗

PubMed2004

Phenotypic selection for residual feed intake and its effect on humoral immune responses in growing layer hens.

According to the resource allocation theory, animals have to make a trade-off between resource-demanding life traits to obtain maximal fitness. Artificial selection toward efficient producing farm animals, however, may have created animals that have an impaired ability to divert resources to maintenance processes, such as responding to immune challenges. Residual feed intake (RFI), defined as the difference between observed feed intake (FI) and expected feed intake based on metabolic BW and growth, was used as a measure for feed efficiency. Individual BW and FI of 352 pullets were recorded weekly from 4 until 14 wk of age to estimate RFI. The top 50 efficient R- and the top 50 nonefficient R+ birds were selected. BW and BW gain in both groups were similar. FI and RFI, however, were significantly higher in R+ birds. Thirty animals out of every group were randomly allocated to 1 of 3 treatments: immunization with keyhole limpet hemocyanin (KLH), Mycobacterium butyricum, or heat-inactivated Salmonella enteritidis bacteria. Antibody titers against KLH, M. butyricum, or Salmonella lipopolysaccharide did not differ between R+ and R- birds. The antibody titer against Salmonella protein was higher in R+ birds. We concluded that a population of chickens from a commercial breed shows considerable variation in RFI. Specific antibody production against KLH, M. butyricum, and S. enteritidis lipopolysaccharide, however, is not influenced by efficiency in terms of RFI. R+ animals may have a higher level of nonantigen specific antibodies, as indicated by the higher antibody response to Salmonella protein.

Animal Feed↗

PubMed1996

Effects of an organochlorine pesticide on different levels of biological organization in Daphnia.

The toxicity of the organochlorine pesticide, endosulfan, to Daphnia carinata was measured at three levels of biological organization: allocation of resources to reproduction, growth and reproductive rates, and population dynamics. The mechanisms by which responses at one level of organization manifest at higher levels are discussed. Two experiments were performed: in the first experiment, groups of Daphnia were exposed to endosulfan at one of three concentrations (0, 40, or 80 microg/liter) and two algal food levels (Selanastrum capricornatum) (1 x 10(5) or 5 x 10(4) cells/ml). Animals were subsampled daily and length, dry weight, egg number, total egg mass, mean egg weight, and timing of reproduction measured. The fraction of available resources that were allocated to reproduction was calculated. In the second experiment, 12 populations of Daphnia were established in flowthrough culture systems. Populations were allowed to grow for 45 days before addition of endosulfan at 0, 40, 80, or 160 microg/liter. Population density, the number of egg-bearing females, and the chlorophyll a concentration in each culture were measured at weekly intervals. The effects of endosulfan on length, dry weight, brood size, and total egg mass were greater at the high food level; however, the timing of reproduction was significantly delayed for the low-food endosulfan-exposed animals. A model is proposed whereby the low-food animals increased the intermolt period to partially offset the costs of endosulfan toxicity. The fraction of available resources allocated to reproduction increased with each instar, although no endosulfan-induced changes could be detected. Daphnia population densities fluctuated in a cyclic manner. Chlorophyll a concentration also fluctuated with peaks coinciding with depressions in the daphnid population density. The effect of endosulfan was to dampen the amplitude of the cycles.

Analysis of Variance↗

PubMed2006

Nutrient availability constrains the hydraulic architecture and water relations of savannah trees.

Leaf and whole plant-level functional traits were studied in five dominant woody savannah species from Central Brazil (Cerrado) to determine whether reduction of nutrient limitations in oligotrophic Cerrado soils affects carbon allocation, water relations and hydraulic architecture. Four treatments were used: control, N additions, P additions and N plus P additions. Fertilizers were applied twice yearly, from October 1998 to March 2004. Sixty-three months after the first nutrient addition, the total leaf area increment was significantly greater across all species in the N- and the N + P-fertilized plots than in the control and in the P-fertilized plots. Nitrogen fertilization significantly altered several components of hydraulic architecture: specific conductivity of terminal stems increased with N additions, whereas leaf-specific conductivity and wood density decreased in most cases. Average daily sap flow per individual was consistently higher with N and N + P additions compared to the control, but its relative increase was not as great as that of leaf area. Long-term additions of N and N + P caused midday PsiL to decline significantly by a mean of 0.6 MPa across all species because N-induced relative reductions in soil-to-leaf hydraulic conductance were greater than those of stomatal conductance and transpiration on a leaf area basis. Phosphorus-fertilized trees did not exhibit significant changes in midday PsiL. Analysis of xylem vulnerability curves indicated that N-fertilized trees were significantly less vulnerable to embolism than trees in control and P-fertilized plots. Thus, N-induced decreases in midday PsiL appeared to be almost entirely compensated by increases in resistance to embolism. Leaf tissue water relations characteristics also changed as a result of N-induced declines in minimum PsiL: osmotic potential at full turgor decreased and symplastic solute content on a dry matter basis increased linearly with declining midday PsiL across species and treatments. Despite being adapted to chronic nutrient limitations, Cerrado woody species apparently have the capacity to exploit increases in nutrient availability by allocating resources to maximize carbon gain and enhance growth. The cost of increased allocation to leaf area relative to water transport capacity involved increased total water loss per plant and a decrease in minimum leaf water potentials. However, the risk of increased embolism and turgor loss was relatively low as xylem vulnerability to embolism and leaf osmotic characteristics changed in parallel with changes in plant water status induced by N fertilization.

Climate↗

PubMed2007

Cancer care, money, and the value of life: whose justice? Which rationality?

Cost-containment in oncology is a moral issue. While economists use the word "rationing" to describe all limitations on resource utilization that result from human choice, the ordinary language distinction between allocation and rationing is morally meaningful and can help oncologists to determine their proper moral role in cost-containment. It is argued that oncologists should not be required to ration at the bedside, nor should they be given financial incentives to practice frugally, nor should they be subjected to a variety of bureaucratic mechanisms to control costs indirectly. In addition, it is argued that the fact that treatments have a price does not logically imply that patients have a price. Cost-effectiveness analysis is often suggested as a means of deciding how best to allocate resources, but some of its many ethical limitations are discussed. The alternative is an open, public, participatory process about how to ration care, abandoning the formulaic pretenses of cost-effectiveness analysis, but with a commitment to reason, good will, and common sense. Oncologists would then be free to advocate for their patients within the constraints imposed by this public process.

Cost Control↗

PubMed2004

Monitoring future impact on malaria burden in sub-saharan Africa.

Ambitious new goals for control of malaria have been set and significant additional resources for malaria control are being mobilized. Yet for many of the countries most severely burdened by malaria, both baseline data and reliable monitoring of key impact indicators is lacking. For such countries, it will be difficult to know when targets are met or whether to make mid-course corrections if progress is inadequate. The new investments in malaria control have triggered resurgence in demand for health information, both for performance-based resource allocation and for health impact. We argue here that some of these resources will need to be diverted to support more integrated information systems able to monitor change and guide approaches, not just for malaria, but also for other important health and poverty related interventions. This paper urges a re-thinking of the nature of management information systems and sources in resource poor settings. A pathway is suggested that helps situate monitoring and evaluation more strategically in a framework of other information management steps for longitudinal, iterative, evidence-based decision making. Health Information Systems of the future will need much greater coherence in the use of information from disparate sources and much greater influence on action.

Africa South of the Sahara↗

PubMed2005

Reprogenetics and pharmacogenetics: in whose best interests?

Reprogenetics involves embryonic pre-implantation genetic diagnosis, provoking controversy over the creation of saviour siblings, eugenics and genetic enhancement. It will soon ascertain pharmacogenetic susceptibilities. Pharmacogenetics impacts upon public health initiatives underpinned by resource allocation constraints in that genetic epidemiological studies assist in administering health care resources and public health strategies. Knowing how likely sections of the population are to develop specific medical conditions so that lifestyle and environmental factors influencing these conditions can be targeted has the potential to save public money and improve public health. Aligning population groups with genetic susceptibilities with specific medications would enable cost-effective prescribing. Reprogenetics and pharmacogenetics also possess great commercial potential for nation states and biotechnology companies. Hence ethical legal safeguards for members of the public whose reproductive or genetic tissue is a research or health care resource are essential. Both legal measures such as informed consent and mechanisms for including the public in policy decisions over reprogenetics and pharmacogenetics must be rethought to ensure that they provide protection rather than function as rubber stamps which preclude deeper inquiry into justifications of projects.

Genetic Research↗

PubMed1997

The use of limited critical care resources: an ethical dilemma.

The following article consists of a review of the literature surrounding the issue of persistent vegetative state (PVS) patients and resource allocation. The author attempts to analyze the question: Should limited critical care resources be used on PVS patients at the risk of denying those resources to others? The author explores such factors as: prognosis and recovery in PVS, life expectancy, and quality of life. As well, resource availability and ICU costs involved in sustaining the life of a PVS patient are examined. Finally, principles such as non-maleficence and beneficence; as well as the critical care professionals attitudes toward this issue; and the moral, ethical, and emotional dilemmas are discussed.

Adolescent↗

PubMedDate not supplied

Evidences on weaknesses and strengths from health financing after decentralization: lessons from Latin American countries.

OBJECTIVE: The main objective was to identify trends and evidence on health financing after health care decentralization. STUDY DESIGN: Evaluative research with a before-after design integrating qualitative and quantitative analysis. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. DATA SOURCES: The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. FINDINGS: The trends and evidence reported in all five financing indicators may identify major weaknesses and strengths in health financing. CONCLUSIONS: Weaknesses: a lack of human resources trained in health economics who can implement changes, a lack of financial resource independence between the local and central levels, the negative behavior of the main macro-economic variables, and the difficulty in developing new financing alternatives. Strengths: the sharing between the central level and local levels of responsibility for financing health services, the implementation of new organizational structures for the follow-up of financial changes at the local level, the development and implementation of new financial allocation mechanisms taking as a basis the efficiency and equity principles, new technique of a per-capita adjustment factor corrected at the local health needs, and the increase of financing contributions from households and local levels of government.

Decision Making, Organizational↗

PubMed2004

Managed care and shadow price.

A managed-care company must decide on allocating resources of many services to many groups of enrollees. The profit-maximizing allocation rule is characterized. For each group, the marginal utilities across all services are equalized. The equilibrium has an enrollee group shadow price interpretation. The equilibrium spending allocation can be implemented by letting utilitarian physicians decide on service spending on an enrollee group subject to a budget for the group.

Health Care Rationing↗

PubMed2000

Economics of prematurity in the era of managed care.

Both the acute intensive care of premature infants and the management of their long-term medical and educational sequelae are costly. Because neonatal intensive care is very effective in reducing mortality, however, its cost effectiveness as described previously is actually quite favorable when compared with other well-accepted medical interventions, such as coronary artery bypass grafting and renal dialysis. This article has highlighted the relatively scant literature on which those estimates of costs and cost effectiveness of both neonatal intensive care and its component interventions rest. This is particularly true with respect to long-term resource use by graduates of NICUs. Without such information, we cannot hope to allocate resources in a way that ensures optimal care of this vulnerable population.

Child Health Services↗

PubMed2000

Event-related brain potentials to attended and ignored olfactory and trigeminal stimuli.

Event-related brain potentials (ERPs) were recorded from 26 young adults, with equal numbers of male and female subjects, using attended and ignored, olfactory and trigeminal stimuli. The amplitudes and latencies of the N1, P2, and P3 components were recorded using a single-stimulus paradigm, with an inter-stimulus interval of 60 s, employing amyl acetate as the olfactory stimulus and ammonia as the trigeminal stimulus. Subjects estimated stimulus intensity in the attend condition or continued with a visual tracking task in the ignore condition. Results indicate that olfactory information is processed 30-70 ms faster than trigeminal information for the N1 and P2 potential and 100 ms faster for the P3 ERP component. N1/P2 interpeak amplitude was greater for the trigeminal than the olfactory stimuli, and greater in the attended than ignored condition. P3 amplitude was greater in the attend than ignore condition for olfactory information processing and equivalent for trigeminal information processing. These findings suggest that neuronal resource allocation is greatest for attended stimuli and that a painful stimulus demands neuronal resources even when ignored.

Adult↗

PubMed1999

Population-based cancer control: where is the greatest benefit from proven strategies to 'regain' years of life lost prematurely?

OBJECTIVE: To apply a 'health gain' approach to population-based cancer control. METHOD: We calculated the potential years of life otherwise lost prematurely which could be 'regained' through implementation of cancer control programs for which Level I or Level II evidence already exists for population outcomes. RESULTS: More potential years of life lost (PYLLs) would be 'regained' by enforcing a 'smoke-free' Australia than by any other possible scenario based on proven effectiveness. Even achievable scenarios for tobacco control (17% or 20% prevalence) would 'regain' more PYLL than either mammographic screening according to national policy or faecal occult blood testing (FOBT) of both men and women over 50 years for colorectal cancer. CONCLUSIONS: As few commentators remain optimistic that more money will be allocated to health, strategic thinking for health gain needs to re-appraise resource allocation for population-based cancer control in Australia. IMPLICATIONS: We recommend wider debate in response to our finding that, on the basis of best available evidence, the greatest potential for health gain lies less in cancer screening than fully funded tobacco control.

Aged↗

PubMed1985

DRGs: how they evolved and are changing the way hospitals are managed.

Medicare uses Diagnosis-related Groups for prospective hospital payments nationwide, but the groups were not originally intended as such. The authors trace the development of this landmark program and explore the concept of product line management. Dr. Fetter, a leading authority in health care resource allocation, developed the entire framework for DRGs as a method to predict hospital resource requirements. He is currently extending the DRG concepts to outpatient and long-term care facilities. This article is adapted from Dr. Fetter's presentation at the Bridgeport Symposium entitled "Performance Requirements for Clinical Laboratories Under Prospective Reimbursement and DRGs." The Nov. 15-16, 1984 symposium was sponsored by Bridgeport Hospital, Bridgeport, Conn., and supported by contributions from 20 companies (listed on page 29). Portions of this article are also based on a presentation by Drs. Freeman and Mullin at the Tri-Service Performance Measurement Conference, June 11-15, 1984, sponsored by the Army Medical Department.

Costs and Cost Analysis↗

PubMed2006

Identifying fitness and optimal life-history strategies for an asexual filamentous fungus.

Filamentous fungi are ubiquitous and ecologically important organisms with rich and varied life histories, however, there is no consensus on how to identify or measure their fitness. In the first part of this study we adapt a general epidemiological model to identify the appropriate fitness metric for a saprophytic filamentous fungus. We find that fungal fitness is inversely proportional to the equilibrium density of uncolonized fungal resource patches which, in turn, is a function of the expected spore production of a fungus. In the second part of this study we use a simple life history model of the same fungus within a resource patch to show that a bang-bang resource allocation strategy maximizes the expected spore production, a critical fitness component. Unlike bang-bang strategies identified in other life-history studies, we find that the optimal allocation strategy for saprophytes does not entail the use of all of the resources within a patch.

Biological Evolution↗

PubMed2006

Is cardiac surgery warranted in children with Down syndrome? A case-controlled review.

OBJECTIVES: To compare children with Down syndrome and children without Down syndrome and investigate whether there is a significant difference in the burden that is placed on the health care system between these two groups only in respect of the repair of congenital heart disease at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. DESIGN: This study is a retrospective case control review. SETTING: Red Cross War Memorial Children's Hospital, Cape Town, South Africa. SUBJECTS: The sample group of 50 Down syndrome children who had received cardiac surgery between January 1998 and June 2003 was compared with a control group of 50 nonsyndromic children who had received cardiac surgery during the same period. OUTCOME MEASURES: Sex and diagnoses (cardiac and noncardiac), number of days spent in hospital and in ICU, complication rates, re-operation rates, early mortality rates, planned further cardiac surgery. Costs of these outcomes were not quantified in exact monetary terms. RESULTS: There was no significant difference between the two groups in terms of the burden that was placed on the health care system. Similar complication rates, re-operation rates and early mortality rates were recorded for both groups. The Down syndrome group appeared to benefit more from cardiac surgery than the non-Down syndrome group. CONCLUSION: Denying cardiac surgery to children with Down syndrome does not improve the efficiency of resource allocation. It is therefore not reasonable to suggest that the problem of scarce resources can be ameliorated by discriminating against children with Down syndrome.

Cardiac Surgical Procedures↗

PubMed1990

Ethical issues encountered in pediatric rehabilitation.

Ethical issues in pediatric rehabilitation should be viewed within the framework of the understanding of the terms of autonomy, nonmaleficence, beneficence and justice. In dealing with the pediatric patient, health professionals are most frequently treating the parents who have the decision-making authority. Normalization which underlies the concept of mainstreaming has become an important issue in pediatric rehabilitation. Normalization is based on the provision of opportunities for choosing, for independent decision making, and for autonomy. The right of the disabled child to have sexual information and to be acknowledged as a sexual individual is essential to the child's autonomy. More children are surviving catastrophic injuries and living with severe disabilities. Birth defects such as myelodysplasias point to the issues of treatment selection involving ethical, moral, philosophical, religious, financial and social values. The phrase 'quality of life' is often applied in these situations and is frequently understood as the 'best interests of the child' which should result in child-centered decisions. In this way, a decision to begin or to withhold treatment can be made in a more ethically considered manner. Resource allocation is of special concern in disabled children since they may consume significant resources in medical and rehabilitation costs spent throughout a lifetime. However, these costs may be justifiable when a disabled child matures into a productive adult. If maximum benefit of limited resources is to be achieved, these children should receive their care from rehabilitation professionals in established centers of rehabilitation expertise. However, we may soon need to accept the responsibility for rationing rehabilitative care as the number of disabled children grows beyond the dollars available to be spent.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗