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Evolutionary perspectives on pregnancy: maternal age at menarche and infant birth weight.

We present a novel evolutionary analysis of low birth weight (LBW). LBW is a well-known risk factor for increased infant morbidity and mortality. Its causes, however, remain obscure and there is a vital need for new approaches. Life history theory, the most dynamic branch of evolutionary ecology, provides important insights into the potential role of LBW in human reproductive strategies. Life history theory's primary rationale for LBW is the trade-off between current and future reproduction. This trade-off underlies the prediction that under conditions of environmental risk and uncertainty (experienced subjectively as psychosocial stress) it can be evolutionarily adaptive to reproduce at a young age. One component of early reproduction is early menarche. Early reproduction tends to maximise offspring quantity, but parental investment theory's assumption of a quantity-quality trade-off holds that maximizing offspring quantity reduces quality, of which LBW may be the major component. We therefore predict that women who experienced early psychosocial stress and had early menarche are more likely to produce LBW babies. Furthermore, the extension of parent-offspring conflict theory in utero suggests that the fetus will attempt to resist its mother's efforts to reduce its resources, allocating more of what it does receive to the placenta in order to extract more maternal resources to increase its own quality. We propose that LBW babies born to mothers who experience early psychosocial stress and have early menarche are more likely to have a higher placental/fetal weight ratio. We review evidence in support of these hypotheses and discuss the implications for public health.

Age Factors↗

Better red than dead: carotenoid-based mouth coloration reveals infection in barn swallow nestlings.

Nestling birds solicit food from their parents by displaying their open brightly coloured gapes. Carotenoids affect gape colour, but also play a central role in immunostimulation. Therefore, we hypothesize that, by differentially allocating resources to nestlings with more brightly coloured gapes, parents favour healthy offspring which are able to allocate carotenoids to gape coloration without compromising their immune defence. We demonstrated that, in the barn swallow Hirundo rustica, (i) parents differentially allocate food to nestlings with an experimentally brighter red gape, (ii) nestlings challenged with a novel antigen (sheep red blood cells, SRBCs) have less bright gape colour than their control siblings, (iii) nestlings challenged with SRBCs but also provided with the principal circulating carotenoid (lutein) have more brightly coloured red gapes than their challenged but unsupplemented siblings and (iv) the gape colour of nestlings challenged with SRBCs and provisioned with lutein exceeds that of siblings that were unchallenged. This suggests that parents may favour nestlings with superior health by preferentially feeding offspring with the brightest gapes.

Animals↗

Estimating local-area needs for psychiatric care: a case study.

BACKGROUND: Different approaches to estimating local catchment-area needs for psychiatric services are illustrated and compared. METHOD: Data from an epidemiological morbidity survey of a random sample of 496 adults were available, as were actual service utilisation rates. Four types of utilisation were modelled (i.e. overall, out-patient, in-patient, emergency clinic) using social indicators available from Statistics Canada census-tract data. Finally, a case-control study compared out-patients from a deprived and an affluent catchment area, matched case by case for primary diagnosis, age, sex and residential status (n = 52). RESULTS: Modelling proved highly predictive of utilisation, the overall-use model accounting for 73% of the variance. The case-control study indicated a higher rate of Axis II traits, substance abuse and needs for social care in the deprived catchment area. CONCLUSIONS: Resource allocation based on the social indicators modelling method was more consistent with sensible distribution of human resources. None of the methods, however, appear to reflect adequately the severity of caseloads evidenced in the case-control study.

Adolescent↗

NAPPH (National Association of Private Psychiatric Hospitals) statement of principles of psychiatric hospital practice ethics.

A competitive and dynamic healthcare environment requires that psychiatric hospital administrators and physicians continually monitor their hospital's ability to deliver quality services to their patients. To ensure that hospitals stand for and abide by psychiatric hospital practice ethics, the National Association of Private Psychiatric Hospitals (NAPPH) Board of Trustees has formally approved and distributed to the industry a "Statement of Principles of Psychiatric Hospital Practice Ethics." Adopted at the June 22, 1989, Board meeting, the guidelines not only summarize views long held in the industry, but are a condition of NAPPH membership. Nine critical areas are identified in the NAPPH statement: admissions, advertising, marketing and referral development, resource allocation and appropriateness of care, treatment rendered, patients' rights, family rights and involvement, competition, and financial resources. Central to ethical hospital practice is a moral responsibility--shared among administrators, trustees, physicians and staff--to ensure access to care, quality of care, and fair treatment of patients. NAPPH represents more than 300 private psychiatric hospitals throughout the United States, and the NAPPH mission includes the promotion of high-quality care and treatment, efficient hospital operation, and advocacy for the patients served by its member hospitals. Each NAPPH hospital actively supports the appropriate, safe, and compassionate treatment of the mentally ill.

Ethics↗

[Program for medicalization of the information systems in France: tool for management and quality assessment?].

OBJECTIVE: We analyzed data reported in the scientific literature to assess how the program for medicalizing information systems employed in France for budget management and allocation could be used to evaluate health care quality. A MANAGEMENT TOOL: In France the PMSI (Programme de Médicalisation des Systèmes d'Information) is used outside health care facilities to plan an allocate health care budgets. Within each facility, it can be used to coordinate external and internal resource allocations. The goal is to medicalize management decisions. Certain methods are based on calculations of total costs per hospital stay and others on the construction of budgets for individual units. A QUALITY ASSESSMENT TOOL: Medical criteria of final outcome of health care, for example mortality, are widely used for inter-hospital comparisons. The PMSI can be a useful tool for monitoring inter-hospital comparisons if three prerequisites are met: comparable data, identification of convenient tracers of care episodes or clinical situations, and multifactorial adjustment to account for variations in rates. The most widely used adjustment factors concern patient characteristics: age, sex, case severity, comorbidity, socio-economic level and hospital characteristics: size and status, number of stays and interventions, emergency and intensive care activity, referral practices.

Delivery of Health Care↗

[Cost methodologies in dialysis in relation to the Italian National Health Service].

This work analyses the economic aspects of dialysis in Italy in relation to government resources allocated to the health service in general. The authors illustrate the procedures used to estimate the resources required by the dialytic programme. The costs of dialytic programmes in different cities and at different periods in the history of the Italian health service are compared. A concrete example is outlined of the economic management of dialysis and the authors demonstrate how the results were obtained using cost analysis.

Health Care Costs↗

Resource Intensity Weights and Canadian hospital costs: some preliminary data.

Different types of inpatients "consume" differing amounts of hospital resources, and it is important to be able to measure these differences in resource consumption. An equitable methodology for funding hospitals must take into account differences in case mix between facilities. An ability to examine these differences in case mix and resource utilization allows hospitals to focus efforts to improve efficiency. A standardized methodology for measuring resource consumption is critical to funding and resource allocation both at a global and organizational level. This study was undertaken to determine whether or not the Canadian system for measuring resource consumption, Canadian Institute for Health Information (CIHI) RIWs, was reflective of the relative cost differences between inpatient cases at the Greater Victoria Hospital Society (GVHS) and to identify RIWs with a significant difference in comparison to GVHS cost weights. A regression analysis was performed on the more than 30,000 inpatient cost profile records from the GVHS 1995-96 cost and patient activity data. The scope of the analysis was restricted to the 424 Case Mix Groups (CMGs) that had a minimum composition of five patient profiles. Comparisons of GVHS cost weights to CIHI RIWs yielded mostly positive results. With the noted exception of about 20 CMGs, there was a high correlation between the CIHI RIW and the GVHS actual cost weights. Hence, the GVHS cost weights can be viewed with confidence as representative of the relative cost differences between typical RIW value CMGs and actual costs.

British Columbia↗

Precise formulation and evidence-based application of resource-constrained triage.

OBJECTIVES: To develop a precise mathematical formulation of resource-constrained triage, denoted the Sacco triage method (STM), to develop an evidence-based application to blunt trauma, and to compare the STM with the simple triage and rapid treatment (START) method. METHODS: Resource-constrained triage is modeled mathematically as a classic resource allocation problem. The objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time-dependent victim survival probabilities based on an initial assessment and expected deterioration. For application to blunt trauma, an "RPM" score, based on respiratory rate, pulse rate, and motor response, was used to predict survivability. Logistic function-generated survival probability estimates for scene values of RPM were determined from 76,459 blunt-injured patients from the Pennsylvania Trauma Outcome Study (PTOS). The Delphi method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. STM was compared with START across various criteria of process and outcome. Outcome was measured by expected number of survivors in simulated resource-constrained casualty incidents. RESULTS: In this mathematical simulation, RPM was a more accurate predictor of survivability from blunt trauma than the Injury Severity Score and the Revised Trauma Score, as measured by calibration and discrimination statistics. STM resulted in greater expected survivorship than START in all simulations. CONCLUSIONS: Resource-constrained triage is modeled precisely as an evidence-based, outcome-driven method that maximizes expected survivors in consideration of resources. The lifesaving potential and operational advantages over current methods warrant scrutiny and further research.

Delphi Technique↗

Local government decision-making and access to primary physician services in Norway.

Public responsibility for health care can be justified by ambitious egalitarian objectives, as it is commonly believed that the private sector generates greater disparities than the public sector. Government institutions can be designed to achieve equality in provision of health services. The article addresses the geographical distribution of primary care physicians in Norway, where primary physician services are the responsibility of local governments, primarily financed by general taxation. The authors analyze the allocation of physicians using a local government demand model, a synthesis of consumers' demand and local government resource allocation. Analyses were performed on a panel data set of all Norwegian municipalities covering the period 1986-1992. The results are encouraging. A decentralized system of primary physician services does seem to be fairly effective in securing equity in access to these services for the municipal population. In particular, local governments seem to respond well to the health care needs of their populations. Distribution of physicians is only to a very small extent dependent on the wealth of the municipality.

Consumer Behavior↗

Allocation of attentional resources during habituation to food cues.

Two experiments were designed to test the hypothesis that habituation to repeated food cues can be inhibited by allocating processing resources to nonfood cues. In two experiments, the salivary response to 10 presentations of lemon yogurt was assessed while subjects engaged in a controlled cognitive search task (demanding attentional resources), an automatic search task (needing fewer attentional resources), or no task. In Experiment 1, the controlled and automatic search tasks differed in the number of memory set items. In Experiment 2, the size of the memory sets was held constant, and individuals were provided practice to stabilize the different search strategies in the task. The automatic search and no task groups habituated to the repeated presentation of food cues in both experiments, but the controlled search group did not. These results support the hypothesis that allocation of attentional resources to external cues can influence the processing of food cues.

Adult↗

Trade-off in investment between dispersal and ingestion capability in phytophagous insects and its ecological implications.

In population ecology, dispersal plays a fundamental role, but is potentially costly. Traditionally, studies of phenotypic trade-offs involving dispersal focus on resource allocation differences between flight and reproduction. However, investments in dispersal may also result in reduced allocation to other "third-party traits" (e.g. compensatory feeding) that are not directly associated with reproduction. Such traits remain largely uninvestigated for any phytophagous insect despite their importance for performance and survival. Using two wing-dimorphic, phloem-feeding planthoppers, Prokelisia dolus and Prokelisia marginata that differ dramatically in dispersal abilities, we sought evidence for a trade-off between investments in dispersal (flight apparatus) and ingestion capability (allocation to the esophageal musculature governing ingestion). Dispersal allows species to meet nutrient demands by moving to higher-quality resources. In contrast, enhanced investment in esophageal musculature increases ingestion capacity and allows phloem feeders to compensate for deteriorating plant nutrition on site. Our objectives were to compare differences in flight and feeding investment between P. dolus and P. marginata and between the wing forms of both species, and to compare ingestion capacity between the two species and wing forms. Morphometric and gravimetric measures of investment in flight versus feeding indicate that the sedentary P. dolus allocates more muscle mass to feeding whereas P. marginata invests more heavily in flight. Likewise, brachypters invest more in feeding and less in flight than macropters. The greater esophageal investment in P. dolus is associated with enhanced ingestion capacity compared to P. marginata. As a consequence, P. dolus is better equipped to meet on-site nutrient demands when faced with deteriorating plant quality than P. marginata, which must migrate elsewhere to do so. Notably, such third-party trade-offs place constraints on how insect herbivores cope with changing resources and set the stage for fundamental differences in population dynamics.

Animals↗

How economists think about family resources and child development.

Research in child development reveals that the sources, level, stability, and uses of family resources have a profound effect on children's well-being and long-term outcomes. Although that research has incorporated economic constructs and measures, developmentalists generally ignore the formal economic framework for thinking about family resources and child outcomes. Building on the premise that children are an investment, that framework explains how families allocate resources and links that decision to other family choices and to key child outcomes, such as schooling, morbidity, and mortality among others. This article explains economists' general approach to family behavior (the so-called theory of household production) and then describes how that framework is useful for thinking about families and children. The article then outlines how economists model parental investment in children and examines the implications of that approach for developmental science. This discussion is illustrated using an example of interest to developmentalists--the involvement of children and adolescents in after-school activities. A concluding section discusses the benefits of and potential barriers to collaboration between economists and developmentalists.

Child↗

Motion - the available treatments for hepatitis C are cost effective: arguments for the motion.

The treatment of hepatitis C has evolved over the past decade, and a combination of interferon (IFN), pegylated or standard type, and ribavirin is now acknowledged as the therapy of choice. Questions remain, however, about the duration of treatment and which patients are the most likely to benefit from therapy. Cost effectiveness analyses (CEAs) have been employed to answer these questions. Before the results can be interpreted appropriately, however, clinicians must make themselves aware of the underlying assumptions and the nature of the 'reference' case. Moreover, certain parameters, including quality-of-life evaluations, may not be easily translated from one jurisdiction to another. The costs and benefits of treatment are often very sensitive to such factors as patient age, viral load, histological severity and the viral genotype. Randomized controlled clinical trials, and the CEAs on which they are based, have shown that combination therapy is more cost effective than IFN monotherapy, and that both are cost effective compared with no treatment. Ongoing research on the use of pegylated IFN, weight-adjusted dosing of ribavirin, and the treatment of relapsers and nonresponders will provide valuable data that could be incorporated into future CEAs. Health care resources are vast, but not limitless. Therefore, health care providers need to become aware of how best to allocate resources to the general population. CEAs can facilitate this process by determining which treatment strategies are likely to yield the greatest clinical benefits without excessive expenditures.

Antiviral Agents↗

Scaling up health interventions in resource-poor countries: what role does research in stated-preference framework play?

Despite improved supply of health care services in low-income countries in the recent past, their uptake continues to be lower than anticipated. This has made it difficult to scale-up those interventions which are not only cost-effective from supply perspectives but that might have substantial impacts on improving the health status of these countries. Understanding demand-side barriers is therefore critically important. With the help of a case study from Nepal, this commentary argues that more research on demand-side barriers needs to be carried out and that the stated-preference (SP) approach to such research might be helpful. Since SP techniques place service users' preferences at the centre of the analysis, and because preferences reflect individual or social welfare, SP techniques are likely to be helpful in devising policies to increase social welfare (e.g. improved service coverage). Moreover, the SP data are collected in a controlled environment which allows straightforward identification of effects (e.g. that of process attributes of care) and large quantities of relevant data can be collected at moderate cost. In addition to providing insights into current preferences, SP data also provide insights into how preferences are likely to respond to a proposed change in resource allocation (e.g. changing service delivery strategy). Finally, the SP-based techniques have been used widely in resource-rich countries and their experience can be valuable in conducting scaling-up research in low-income countries.

Editorial↗

Unmet expectations for care and the patient-physician relationship.

OBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations. DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit. SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians. PATIENTS: Nine hundred nine adults reporting a health problem or concern. MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled. CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.

Cardiology↗

Consumer directed health care: ethical limits to choice and responsibility.

As health care costs continue to escalate, cost control measures will likely become unavoidable and painful. One approach is to engage external forces to allocate resources--for example, through managed care or outright rationing. Another approach is to engage consumers to make their own allocation decisions, through "self-rationing," wherein they are given greater awareness, control, and hence responsibility for their health care spending. Steadily gaining popularity in this context is the concept of "consumer directed health care" (CDHC), which is envisioned to both control cost and enhance choice, by combining financial incentives with information to help consumers make more informed health care decisions and to appreciate the economic trade-offs of those decisions. While CDHC is gaining attention in the popular press, business publications, and academic journals, it is not without controversy about its relative merits and demerits. CDHC raises questions regarding the ethical limits of consumer responsibility for their choices. While the emphasis on consumer choice implies that autonomy is the ruling ethical principle in CDHC, it must be tempered by justice and beneficence. Justice must temper autonomy to protect disadvantaged populations from further widening disparities in health care access and outcomes that could arise from health care reform efforts. Beneficence must temper autonomy to protect consumers from unintended consequences of uninformed decisions. Thoughtful paternalism suggests that CDHC plans offer choices that are comprehensible to lay consumers, limited in their range of options, and carefully structured with default rules that minimize potential error costs.

Bioethics↗

Exploring policy and financing options for long-term care in Taiwan.

Policy and financing arrangements for long-term care are important themes in each country and/or region, and Taiwan, with its unique historic and politico-economic background, can be regarded as a bridge between well-developed and under-developed countries. Policy formulation about long-term care in Taiwan involves several agencies in the government, including Ministry of Health, Interior Affairs, Education, Insurance Bureau, and Economic Council, and formulation of policy objectives has progressed considerably in the last five years. Financing arrangements are less well-developed because the National Health Insurance Program began only in 1995, and most long-term care is not yet covered. As demand for long-term care exceeds supply, and this gap will grow in future, current resource allocation measures are concerned to facilitate the expansion of community care rather than allowing institutional care to absorb more resources. Developing future financing options is now a central task for policymaking, and government must continue to take a leading role in consolidating financial and integrating the service systems.

Aged↗

The burden of cancer in Kentucky: the 1997 Kentucky cancer incidence report.

The purpose of collecting this important disease burden information is of course not simply for reports like this one. The real value lies in use of data for program planning, resource allocation, program design, and evaluation. Data in the annual KCR report and on the website should be a valuable resource for district and county health departments in their assessment of health problems in their area and as critical decisions are made about how to utilize limited intervention resources. The Kentucky Cancer Registry will continue to work very closely with the Community Outreach Division of the Kentucky Cancer Program to make this data available on an annual basis to District Cancer Councils to help guide their assessment and planning process. District and local health departments are encouraged to actively participate in the District Cancer Councils and in the cancer control activities guided by the regional community outreach coordinators.

Adolescent↗