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PubMed2004

Allocation or misallocation of limited medical resources.

Very small premature babies are now kept in neonatal intensive care units for many months to give them a chance at near normal life, but at a cost of up to dollars 1 million. Is that a proper allocation of our finite medical resources (personnel, equipment, supplies, and other necessities) for premies? Or is such action a misallocation of these resources? Both sides of the argument have positive and negative merit. A final philosophical statement is that each human created in the image of God has supreme value. It is it the obligation of fellow humans and society in general to preserve and dignify human life and to care for the total needs of individual citizens to enable them to be healthy and productive members of society. This general principle should help individual physicians make proper microallocation life and death decisions for individual patients and assist governmental bodies responsible for making macroallocation decisions concerning the short- and long-term needs and priorities of the population as a whole. All such decisions should be guided by the basic ethical principles of beneficence, nonmaleficence, autonomy, and justice. However, these principles may at times conflict. For example, if the autonomous rights of the patient conflict with the justice appeals of the community or if beneficence to an individual patient conflict with the needs of another patient, can we deny health care services? By what criteria (merit, potential, effort, achievement, age)? These are difficult if not impossible questions to answer, but they pertain to the topic of this commentary on the allocation of limited medical resources, which is meant to raise the sensitivity of the reader to the complexity of the problem and to raise ethical questions, which are not easily answered or dealt with.

Health Care Rationing↗
PubMed1999

Complex Life Cycles in a Variable Environment: Predicting When the Timing of Metamorphosis Shifts from Resource Dependent to Developmentally Fixed.

To test models of the timing of and size at metamorphosis, researchers manipulate food at several times during the larval phase of an animal's complex life cycle. Data from diverse taxa show that the age at metamorphosis becomes resource independent (i.e., fixed) at some point during the larval phase. Although existing models have been modified to incorporate a fixed rate of development, none predicts when phenotypic plasticity in metamorphic timing is lost. A graphical model is presented that extends knowledge of a genotype's optimal age and size at metamorphosis in different environments in which resources remain constant throughout the larval phase (i.e., the genotype's reaction norm) to predict when development rate becomes fixed in response to resource variability during the larval phase. Model predictions concur with data from food-switching experiments on anuran tadpoles and barnacle nauplii. As interest in the timing of and size at metamorphosis expands from well-studied taxa (e.g., amphibians) to the many others that have complex life cycles, the predictive model provides a useful tool to design and improve experiments.

Wilbur‐Collins model↗
PubMed2003

Suitable monitoring approaches to antiretroviral therapy in resource-poor settings: setting the research agenda.

The delivery of antiretroviral therapy in the developing world requires guidelines for the appropriate monitoring of therapy, including monitoring for treatment effectiveness and treatment failure, drug toxicities, adherence to therapy, and the emergence of resistant organisms. Guidelines developed in wealthy industrialized countries, which rely heavily on laboratory tests often unavailable in the developing world, may not be feasible or appropriate for resource-limited settings. Even if the standard of care routinely delivered in industrialized settings cannot be replicated, antiretroviral treatment programs with less-intense monitoring have the potential to reduce morbidity and mortality from human immunodeficiency virus. Research to identify monitoring strategies that provide the greatest benefit to those living with human immunodeficiency virus in resource-limited settings and that use the available technologies and resources needs to be conducted within a conceptual and ethical framework that takes into account differences between rich and poor countries.

Anti-HIV Agents↗
PubMed1997

RUG-III and resource allocation: comparing the relationship of direct care time with patient characteristics in five countries.

BACKGROUND: resource use by different types of patients is of increasing interest to health care services all over the world. Case-mix systems that group together individuals with similar patterns of resource use have been developed to address these questions. Resource Utilization Groups version III (RUG-III) was developed in the USA to address the issue in the care of elderly people and has been validated in a number of countries. METHOD: this paper synthesizes the results of RUG-III validation studies performed in the USA, Japan, Spain, Sweden and England and Wales, showing the consistency of the system in spite of different skill-mix and total time spent with patients. Data from the validation studies of five countries were compared. Percentage of time given by trained nurses and mean nursing time per patient was compared overall and between selected RUG-III groups. RESULTS: mean time per patient ranged from 84.4 min per day in Japan, to 155.6 min in England and Wales. Trained nurse time ranged from 7.5% of total time in the USA to 53.2% of total time in England and Wales. The inter-group relationship was very similar in all countries. The RUG-III system appears robust in a wide variety of settings and countries. Future research should address the relationship between skill-mix and total time spent with patients with respect to outcome and quality of care.

Activities of Daily Living↗
PubMed1996

Disease management program for asthma: baseline assessment of resource use.

Resource use by asthma patients was assessed as a step in the development of a disease management program by a university teaching hospital, a health maintenance organization (HMO), and a national pharmacy benefit management company (PBM). Medication profiles and medical records were reviewed for all HMO patients who had a diagnosis of asthma and a pharmacy claim for an asthma-related drug in 1993; patients with chronic obstructive pulmonary disease were excluded. These 656 patients' use of health care resources (outpatient clinic visits, emergency room and urgent care visits, hospital admissions, and, the associated costs were determined, as were variances from the PBM's clinical guidelines for asthma. Members 0-4 years of age had the most outpatient and emergency/urgent care visits and the most hospital admissions. Forty-four of the patients received high-dose beta-agonist therapy, and 20 of these patients did not receive either an inhaled anti-inflammatory drug or a short course of corticosteroids. The 44 patients had more outpatient clinic and emergency room/urgent care visits, more admissions, and greater total health care costs than the other patients with asthma. The asthma patients' mean health care cost in 1993 was $203, compared with $110 for all enrollees in the HMO. For patients with high use of beta-agonists, the mean cost was nearly three times that for the other asthma patients. The baseline review of resource use identified aspects of medication use that were at variance with treatment guidelines for asthma patients.

Adrenergic beta-Agonists↗
PubMed2004

The impact of delayed chemotherapy-induced nausea and vomiting on patients, health resource utilization and costs in German cancer centers.

BACKGROUND: Delayed chemotherapy-induced nausea and vomiting (CINV) remains a major adverse effect of cancer chemotherapy. We assessed, under current practice patterns, the occurrence and impact on healthcare resource utilization of CINV in patients receiving emetogenic chemotherapy. An additional aim of this study was to estimate costs imputable to CINV in the German healthcare environment. MATERIALS AND METHODS: This prospective, multi-center, cross-sectional cost-of-illness study was conducted in three hospitals and in three office-based facilities in Germany. Consecutive patients undergoing emetogenic chemotherapy (levels 4 or 5 according to Hesketh classification of emetogenicity) were enrolled. Data were obtained from preplanned chart reviews and from self-administered patient questionnaires. Analysis of direct costs was performed from the perspectives of third party payer (statutory sick fund), provider (hospital) and patients. Indirect costs were assessed on the basis of paid workdays lost. RESULTS: During the 5-day observation period, 134 of 208 chemotherapy cycles observed (64.4%) were associated with at least one episode of nausea or vomiting. More patients experienced delayed than acute CINV (60.7% versus 32.8%), and more patients reported nausea than vomiting (62.5% versus 26.0%). A total of 68 patients (32.6%) utilized healthcare resources due to CINV. The most frequently used resources were rescue medications and outpatient hospital and office physician visits. Only one patient required hospitalization and only three patients lost workdays due to CINV. Average costs imputable to CINV per patient (with or without CINV) per treatment cycle incurred by third party payers and hospital providers were Euro 49 and Euro 48, respectively. Patient or treatment characteristics that were associated with high costs imputable to CINV were as follows: cisplatin-containing regimen; experience of emesis; and presence of delayed CINV. CONCLUSIONS: A substantial proportion of patients continue to experience CINV. This entails not only clinical but also economic consequences, and highlights a continuing need for improved utilization of existing antiemetic agents and for new, more efficacious treatments. The greatest improvements in patient care and potential for cost offset may be realized by preventing delayed CINV.

Antiemetics↗
PubMed1998

Infants conceived using in-vitro fertilization do not over-utilize health care resources after the neonatal period.

Health outcomes during the first year for 95 infants born following in-vitro fertilization (IVF) were compared with those of 79 naturally conceived controls whose mothers were of identical parity and similar age. Primigravid women were enrolled prospectively at 30 weeks gestation, perinatal and neonatal data were collected during pregnancy and following birth, and details of health care resource use were obtained from mothers at 4 and 12 months. Median (range) number of medical problems during the first year tended to be less for IVF infants, 4 (0-41) versus 5 (0-12) (P = 0.07), whilst total number of visits to health care workers was similar for IVF and control infants, 19 (2-47) versus 19 (1-47). IVF infants were more likely to have an excessive number of visits to Early Childhood Health Care Centres [odds ratio (OR; 95% confidence interval, CI) = 2.44 (1.11-5.56)], but less likely to have an excessive number of visits to general medical practitioners [OR = 0.45 (0.22-0.93)] and other health care workers [OR = 0.48 (0.23-0.99)]. These data provide some degree of reassurance about medium-term health outcomes for children conceived using IVF. Although they are more likely to utilize the resources of neonatal intensive care units, IVF infants do not appear to have an increased number of medical problems or to over-utilize health care resources during the remainder of their first year of life.

Adult↗
PubMed2000

Genome resource banking for wildlife research, management, and conservation.

Cryobiology offers an important opportunity to assist in the management and study of wildlife, including endangered species. The benefits of developing genome resource banks for wildlife are profound, perhaps more so than for traditional uses in terms of livestock and human fertility. In addition to preserving heterozygosity and assisting in the genetic management of rare populations held in captivity, frozen repositories help insure wild populations against natural and human-induced catastrophes. Such banks also are an invaluable source of new knowledge (for basic and applied research) from thousands of species that have yet to be studied. However, it is crucial that genome resource banks for wildlife species be developed in a coordinated fashion that first benefits the conservation of biodiversity. Spurious collections will be of no advantage to genuine conservation. The Conservation Breeding Specialist Group (CBSG; of the International Union for the Conservation of Nature and Natural Resources' Species Survival Commission) has promoted international dialogue on this topic. CBSG working groups have recognized that such repositories be developed according to specific, scientific guidelines consistent with an international standard that ensures practicality, high-quality ethics, and cost-effectiveness. Areas requiring priority attention also are reviewed, including the need for more basic research, advocacy, and support for developing organized repositories of biomaterials representing the world's diverse biota.

Animals↗
PubMedDate not supplied

The SECCAT Survey: II. The Alcohol Related Problems Questionnaire as a proxy for resource costs and quality of life in alcoholism treatment. Study of Socio-Economic Consequences and Costs of Alcoholism and Treatment.

An interview was obtained with 212 patients who had, at a point 12 months previously, been in contact with an alcohol problems clinic. Quality of life (SF-36) was measured and for the preceding 6 months the cost of health and social service resource use was estimated, together with the total abstinent (or controlled drinking) days accrued. Alcohol related health, personal and social problems experienced during that period were elicited using a brief 11-item questionnaire, the Alcohol Related Problems Questionnaire (ARPQ). The estimate of costs correlated more strongly with the ARPQ score (r = -0.32, P = 0.0001) than with abstinent days (r = 0.03, n.s.) or controlled drinking months (r = -0.21, P = 0.002). The lack of relation of total abstinent days to cost is partly because abstainers tended to use considerable alcohol problems clinic resources. ARPQ scores indicating more problems were associated with lower quality of life. The ARPQ can serve as a proxy for resource use and quality of life in alcoholism treatment.

Adult↗
PubMed1989

NHS resource allocation after the 1989 white paper: a critique of the research for the RAWP review.

The Government White Paper on the NHS, 'Working for Patients', abolished the Resource Allocation Working Party (RAWP) formula in name, but retained its general approach of ensuring geographical equity through funding health authorities by a system of weighted capitation. As a result, the longstanding debate about the appropriate need indicators to include in RAWP, which was tackled afresh in the recent NHS Management Board review of RAWP, will remain highly pertinent to NHS resource allocation in the 1990s. Yet, the research carried out for the RAWP review, on which its principal proposals for change to the need indicators were based, is inadequate for developing a new method of resource allocation after RAWP. The paper describes the research and sets out its main conceptual limitations and problems of method.

Catchment Area, Health↗
PubMed2004

Acute and chronic paediatric intensive care patients: current trends and perspectives on resource utilization.

BACKGROUND: Advances in paediatric critical care have resulted in increased survival of critically ill patients, many of whom require long-term ventilation as a means of life support. AIM: To determine current trends in resource utilization, and problems in the care of acute and chronic paediatric intensive care patients. DESIGN: Open observational study. METHODS: We evaluated consecutive admissions (n = 1629) to a 10-bed paediatric intensive care unit (PICU) over a 5-year period. Three previously defined criteria for resource utilization were used: mean length of stay (LOS); length of mechanical ventilation (LOMV); and LOMV/LOS ratio. RESULTS: A total of 10 310 patient bed days and 5223 ventilator days were used. Mean LOS increased from 5.3 +/- 12 days in 1998 to 8.7 +/- 27 days in 2001 (p < 0.05). Although LOMV/LOS ratio (50.7%) was significantly correlated with Paediatric Risk of Mortality score (p < 0.0001), there was no significant change in mortality rate (12.6% vs. 12%). Patients hospitalized for >2 weeks (n = 320, 20%) used 55% of LOS and 57% of LOMV, in contrast to the 1298 (80%) hospitalized for <7 days, who used only 29% of LOS and 20% of LOMV. Patients hospitalized for >3 months (11, 0.7%) consumed 17% of LOS and 23% of LOMV. Five of these (45%) were eventually discharged home, two on ventilators. CONCLUSION: The increasing trend of occupation of PICU bed and ventilator days by critically ill children may be related to the increasing trend for hospitalization of chronic care patients. Severity scoring systems were predictive of resource consumption, but not of the overall trend in mortality rate.

Acute Disease↗
PubMed1988

Hospital resources used for inpatient and ambulatory surgery.

New hospital and physician payment schemes encourage physicians to participate actively in efforts to minimize hospital resource use. As an example of the type of evaluations anesthesiologists may conduct, we examined hospital resources used for comparable groups of inpatients (INPTs) and day surgery unit (DSU) patients. Although INPTs and DSU patients undergoing surgical arthroscopy of the knee or diagnostic laparoscopy were similar with regard to age, physical status, and staff surgeon, more preoperative tests were performed for INPTs than for DSU patients (P less than .05). Hospital costs for these tests were four times greater for INPTs than for DSU patients. Operating room time was from 20 to 45 min longer for INPTs than for DSU patients (P less than .05). Recovery room time was from 25 to 52 min longer for DSU patients (P less than .05). Per patient nursing labor costs paralleled operating and recovery room times. These kinds of analyses are important in identifying opportunities to improve resource use, in assessing institutional costs for surgical care, and in designing strategies that allow institutions and physicians to respond to cost containment pressures.

Ambulatory Surgical Procedures↗
PubMed2003

Resources, use, and regionalization of pediatric cardiac services.

Care for children with congenital heart disease requires specialized services and various healthcare resources. The purpose of this article is to provide an updated overview of healthcare resources for infants and children with heart disease. In 2001, there were 1609 certified pediatric cardiologists in the United States. The ratio was approximately 45,000 children younger than 18 years per pediatric cardiologist. It is estimated that more than 19,000 cardiac surgeries are performed in children younger than 18 years in the United States each year. This article also reviews the effect of patient characteristics on access to healthcare and use of pediatric cardiac services, and discusses issues related to optimal use of these resources and the development of an organized approach toward service management by regionalization. The authors believe that improved access to high-quality facilities and providers coupled with thoughtful changes in the healthcare delivery system represent an excellent opportunity for optimizing outcomes for children with heart disease.

Cardiac Surgical Procedures↗
PubMed2002

Resource requirements to fight HIV/AIDS in Latin America and the Caribbean.

OBJECTIVES: Economists and epidemiologists from 10 countries in Latin America and the Caribbean (LAC) reviewed the methods used to develop estimates for resource requirements to address HIV/AIDS prevention and care in low- and middle-income countries. METHODS: They applied their country-specific knowledge to re-estimate the costs, coverage, and capacity of their health and education systems to expand HIV/AIDS interventions by 2005. A discrepancy of 173 million US dollars exists between the model estimates and those of country specialists. RESULTS: The most important difference between the model estimates and those of country specialists was in the estimated future price of highly active antiretroviral therapy. To a large extent, the estimates of the model reflect the efficiency gains that could result from purchasing arrangements that lead LAC countries to lower prices for antiretroviral drugs. CONCLUSION: This preliminary exercise with 10 LAC countries confirmed the validity of the use of these estimates as tools at the international level, given current data limitations, both to guide the allocation of resources across diseases and countries, and for advocacy and resource mobilization. In addition, with the country revisions, these estimates have also been shown to be key tools for country-level strategic planning.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units.

OBJECTIVES: Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness. DESIGN: A prospective, observational study. SETTING: The coronary care and intermediate care unit in an 1,100-bed community hospital. PATIENTS: A total of 217 patients hospitalized for chest pain cared for by noncardiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer. CONCLUSIONS: There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.

Age Factors↗
PubMed1995

Do elderly patients overutilize healthcare resources and benefit less from them than younger patients? A study of patients who underwent craniotomy for treatment of neoplasm.

OBJECTIVE: Some physicians and academicians have suggested that limiting selected healthcare resources to the elderly will help curtail the rising cost of health care in the United States. In order to test this hypothesis in a specific medical context, we compared the cost of caring for younger (< 65 yrs) patients with that of caring for older (> or = 65 yrs) patients who underwent craniotomy for treatment of brain tumors. DESIGN: Prospective collection and review of data on patients undergoing craniotomy for tumor in our institution between February 1989 and December 1991. SETTING: University teaching hospital. METHODS: Patients were divided into two groups: those < 65 yrs, and those > or = 65 yrs. Demographics, severity of illness, length of stay, hospital and surgical intensive care unit (ICU) costs and charges, ICU complications, procedures, and outcome variables were analyzed. RESULTS: Of 3,265 ICU patients admitted during the study period, data on 123 (3.8%) undergoing craniotomy for brain tumor were analyzed. There were no differences between the patient groups in length of ICU stay or hospital stay, final outcome at discharge from the hospital, quality of life, or hospital or ICU costs, despite the fact that elderly patients had a greater number of procedures and complications per patient, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of illness scores on admission and discharge than younger patients. CONCLUSIONS: The assertion that the elderly may, under certain conditions, consume more healthcare resources and benefit less from them than younger patients must be tested for accuracy with regard to specific disease states. In the context of the disorder studied herein, the elderly do as well as the young. Without specific study of specific pathologic processes or surgical procedures, using age to limit access to resources remains an unsubstantiated, ideologic concept, rather than a scientifically proven cost-saving measure.

APACHE↗
PubMedDate not supplied

Self-care resources and activity as predictors of quality of life in persons after myocardial infarction.

An ex post facto correlational study was conducted to examine predictors of quality of life in persons 3 to 6 months after a myocardial infarction. Self-care resources, self-care knowledge (needs), activity level, and selected demographic variables were examined as predictor variables. A convenience sample of 86 subjects with a mean age of 61 years, was recruited for participation in this study. The study that explained 35% of the variance in quality of life included self-care resources available, activity level, and self-care needs. Modeling and Role Modeling Paradigm provided a useful explanation of how self-care resources and self-care knowledge can be applied to persons recovering from myocardial infarction.

Activities of Daily Living↗
PubMedDate not supplied

Is it resources, habit or both: interpreting twenty years of hospital strategic response to prospective payment.

The 1983 Tax Equity and Fiscal Responsibility Act (TEFRA) transformed acute care from a benevolent to malevolent environment. A dual-paradigm of resource dependency and institutional theories that balances isomorphic with economic variables has emerged to better explain hospital strategic response to the resultant constraint on resources than a traditional single paradigm approach. Using the population of non-rural, non-federal acute-care hospitals, strategic response from 1982 to 2001 is studied; distinct cost and service changes occur. Cost strategy is linked primarily to Medicare utilization, a resource dependence response. Service strategy favors high technology regardless of prospective payment diffusion, an institutional theory perspective. Strategic implications are discussed.

Acute Disease↗