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PubMed1992

Measuring outcome of total knee replacement using quality of life indices.

A series of 26 patients was studied before and after total knee replacement to determine the change in their quality of life, expressed as a gain in Quality Adjusted Life Years (QALYs). Global health status was assessed using the Nottingham Health Profile, disability by the Harris scale, pain by the McGill Pain Questionnaire, and anxiety and depression by the Hospital Anxiety and Depression Scale. Substantial reductions were found in pain, anxiety and depression, and a significant improvement was found in mobility. These data were used to generate a 'QALY' (Quality Adjusted Life Year) comparable to the measure used by Williams (1) in his comparative evaluation of medical and surgical treatments. A gain of only 0.42 QALY was found for knee replacement, which is about one-tenth the figure given by Williams for hip replacement. The difference appears to be attributable not to differences in the success of the operations, but rather to the scope that QALY calculations give for allocating comparable patients to different quality of life states. Tighter criteria are needed if QALYs are to be used to guide resource allocation.

Aged↗
PubMed2004

Veterans' health care: balancing resources and responsibilities.

This paper looks at the health care benefits and services administered by the U.S. Department of Veterans Affairs. It examines management strategies adopted within the department to allocate resources, structure benefits, and improve quality. Some recommendations made by the General Accounting Office and the President's Task Force to Improve Health Care Delivery for Our Nation's Veterans are reviewed, in particular the emphasis of the latter on increased collaboration with the Department of Defense. Long-term proposals to balance service commitments and financing also are considered.

Delivery of Health Care, Integrated↗
PubMed1990

Ethical aspects in the care of very low birth weight infants.

Advances in the neonatal intensive care (NIC) of the very low birth weight infant (VLBW) have given rise to important ethical questions. (1) Does every VLBW infant have the right to NIC? (2) Who should decide whether to treat? (3) How should resources be allocated for NIC? To play their part in answering these questions, paediatricians must become familiar with the principles of ethical reasoning. A distinction can be drawn between a human being and a human person on the basis of the possession of certain qualities, in the absence of which non-treatment may be justified. It will usually not be possible to make this distinction prospectively and hence it is not of much practical assistance as a criterion for decision making. Future disability of th infant can also be advanced as a reason for non-treatment, but it is not possible to know whether avoidance of disability makes it in the best interest of the infant to not be treated, and hence probable future disability is not per se an acceptable criterion for non-treatment. Pain and distress, however, is within the comprehension of decision makers and its avoidance may be an acceptable criterion for non-treatment (although in practice rarely a helpful one). The most useful criterion is one based on the ethics of resource allocation. Resources should be allocated in accordance with the ethical principles of justice and full beneficence. Criteria based on prognosis should be established to decide which VLBW infants should share in the finite resources directed to NIC.

Child Advocacy↗
PubMed2002

Making choices in healthcare: the reality of scarcity.

Processes are required to aid decision-makers in better managing existing resources in healthcare. To date, limited research has informed priority setting at the macro level, across broad service areas, within health organizations. As part of a participatory action research project, a macro-level resource allocation framework was developed and implemented in the Calgary Health Region (CHR). The approach relies on an expert panel of managers and clinicians who are charged with identifying, on the basis of evidence and local information, how resources might be reallocated to improve population well-being. The framework developed was seen as an improvement over historical allocation processes.

Alberta↗
PubMedDate not supplied

The equity principle in the allocation of health care expenditure on primary health care services in Portugal: the human capital approach.

This article examines the equity principle as it could be applied to the financing of primary health care resources in Portugal. Three resource allocation criteria are considered: namely, the demand/utilization criterion; the health situation criterion; and, the coverage by health services criterion. With data based on health service expenditure, district by district, for 1983, the article shows that quite different results would emerge from the selection of one criterion rather than another. In particular, a policy of positive discrimination would reallocate resources towards the north rather than the south of Portugal, though differences would emerge between districts and between specific activities provided within the framework of primary health care. The results are presented and conclusions drawn.

Health Expenditures↗
PubMed2001

Community values and preferences in transplantation organ allocation decisions.

This paper is concerned with community values and preferences in organ transplantation allocation decisions. With recent trends in organ shortages, transplant teams face difficult allocation decisions amongst increasing numbers of "worthy" potential recipients. It is argued that the debate about these decisions ought to be informed in part by a systematic knowledge of prevailing community standards. A community sample of 238 adults (140 women and 98 men, with a mean age of 47.0 years) completed a questionnaire concerning which factors ought to affect recipient priority for transplantation. Longer waiting time, better prognosis, younger age and being a parent were the most frequently selected criteria for organ allocation decisions. The participants also rank ordered 16 potential recipients presented in the form of case scenarios in terms of priority for transplantation. The 16 case scenarios were constructed from a factorial combination of four variables: age of recipient (young vs old); the time the recipient had been on a waiting list (long vs short); recipient prognosis (excellent vs fair); and parental status (children vs no children). It was found that one case scenario involving a young parent with an excellent prognosis and long waiting time was ranked first by 75.2% of all participants. Analysis revealed that transplant recipient age and prognosis were the most influential factors in determining the priority rankings for organ allocation. The study has demonstrated that judgement and decision analysis procedures can be used to elicit community values and preferences about complex resource allocation decisions.

Adult↗
PubMed1995

Cost-effectiveness in ambulatory care: alternative approaches.

By relating health care resources and their use to health outcomes, through a coherent macro resource allocation framework, one can examine the health care system for allocative efficiencies. In this article, costs and outcomes are analyzed in such a framework, scenarios for optimizing the use of health care resources--while still maintaining existing health outcomes--are explored, and the implications for ambulatory care are discussed. The research clearly shows that much can be done to make health care systems more efficient without jeopardizing health outcomes.

Ambulatory Care↗
PubMedDate not supplied

Strategies for developing an evidence-based approach to perinatal care.

Today more than ever perinatal care providers must work together to develop practice patterns that will contribute to the best possible outcomes for women and newborns. Financial and human resource allocation are under intense scrutiny in most hospitals. Although the fundamental goals of health care institutions are to maximize health while conserving resources, unfortunately, these goals are often in conflict. Perinatal practice must be based on the combined weight of all available evidence rather than "the way we've always done it." Health care institutions that continue doing business as usual are not likely to survive. Using both clinical and financial data, routine perinatal practices without a scientific basis that establish a contribution to improved outcomes can be reevaluated, while practices that have been shown to be beneficial can be enhanced and supported. The first step in developing a standards and evidence-based approach to perinatal care is the establishment of a practice committee in which communication is open and direct and there exists a respect for the contributions of members from all related disciplines. True collaboration and communication between physicians and nurses is the foundation for establishing and implementing best practices. Fortunately, a growing body of research regarding the pros and cons of various perinatal practices is beginning to emerge; this research can be used by knowledgeable, informed perinatal professionals to advocate for a clinically appropriate approach to fiscal prudence. Commitment to practice based on standards and evidence is an ongoing process and may require substantial changes and more professional energy than the usual methods of implementing and evaluating changes in patient care routines. However, the initial investment in time to collaborate and become oriented to this process is worth the effort.

Cost Control↗
PubMed2006

Equilibration through local information exchange in networks.

We study the equilibrium states of energy functions involving a large set of real variables, defined on the links of sparsely connected networks, and interacting at the network nodes, using the cavity and replica methods. When applied to the representative problem of network resource allocation, an efficient distributed algorithm is devised, with simulations showing full agreement with theory. Scaling properties with the network connectivity and the resource availability are found.

Journal Article↗
PubMed2000

Carbon and nitrogen allocation to male and female reproduction in Rocky Mountain Douglas-fir (Pseudotsuga menziesii var. glauca, Pinaceae).

We measured carbon (respiration, photosynthesis, and production) and nitrogen allocation to male and female cones of Rocky Mountain Douglas-fir (Pseudotsuga menziesii var. glauca) to quantify gender-specific: (1) resource allocation to reproduction, and (2) contribution to carbon costs of reproduction via photosynthesis. We also measured foliar photosynthesis and nitrogen concentration ([N]) near and far from female cones to examine the relationship between reproduction and foliar physiology. Over one growing season, male cones required only 8% of all carbon allocated to reproduction, with females consuming the remaining 92%. Female cones, however, had maximum instantaneous refixation rates of 54%, which, integrated over the season, offset 6% of their total carbon requirements, while male cones were completely dependent on vegetative tissues for carbon. Male cones received 22% of all nitrogen allocated to reproduction and female cones received the remaining 78%. Foliage near female cones had elevated photosynthesis during the early stages of cone development and consistently lower [N] than foliage far from cones. Although female cones may photosynthesize, the annual sum of carbon fixed by reproductive structures is minor in comparison to the total carbon allocated to production and respiration.

Journal Article↗
PubMed2005

[Results summarize of the project of "reestablishing disease prevention and control system of China"].

This paper introduced the following study results of the project of "reestablishing the disease control and prevention system of China" in brief: (1) the chief problem existed in disease control and prevention system of China is the lower fulfilling level of public functions. (2) the parents of this chief problem are the lower financing level and the lower managing responsibility of government. (3) to reestablish the disease control and prevention system of China, government should increase the investment and strengthen management, which may need the following preconditions: more government recognitions to the disease control and prevention, more government investment, more sustainable government investment, higher efficiency of CDC, more competitive salary system to recruit specialists, more reliable disposal about non-public-product provided by CDC. (4) the public functions of CDC could be defined as 7 categories and 255 items. (5) according to the calculating method of human resources allocation of CDC which has been developed and demonstrated by the project team, 159086 persons, which is equal to 76.9% of human resources of CDC in 2002, are needed to fulfill all the public function of CDC throughout the country. (6) based on the model of input-output analysis, to exclude the non-public-service of CDC, government should give another yen 10.29 billions on the basis of current 3.9 billions of government investment to CDC.

China↗
PubMed1993

A theory of hospital waiting lists.

The noncooperative character of resource allocation in a national health service may contribute to excessive waiting lists. A theory of hospital waiting lists is derived from this idea. Waiting lists imply loss of efficiency; the hospital's resources are drawn away from medical work. Although there is scope for Pareto improvements, the structure of budget allocation may prevent these improvements from being achieved. Some reforms of the institutional structure are suggested.

Budgets↗
PubMed1990

Neighbourhood of domicile and hospital admissions in Auckland: is there a relationship?

The relationship between the health and equity index of socioeconomic status/need and hospital admission rates has been investigated. The index is based on an area's population characteristics, and has previously been used for determining service provision and to describe an area's health need. This study demonstrates a strong positive correlation (r = 0.88, 95% confidence intervals 0.75 to 0.94) between the index and standardised hospital admission rates in the Auckland urban area. This association validates the index as a proxy for morbidity, in as much as hospital admission rates measure morbidity, and supports suggestions for its use to alter interregional and intraregional resource allocation.

Adolescent↗
PubMed1982

Dividing attention within and between hemispheres: testing a multiple resources approach to limited-capacity information processing.

Two experiments tested the limiting case of a multiple resources approach to resource allocation in information processing. In this framework, the left and right hemispheres are assumed to have separate, limited-capacity pools of undifferentiated resources that are not mutually accessible, so that tasks can overlap in their demand for these resources either completely, partially, or not at all. We tested all three degrees of overlap in demand for left hemisphere supplies, using dual-task methodology in which subjects were induced to pay different amounts of attention to each task. Experiment 1 compared complete and partial overlap by combining a verbal memory load with a task in which subjects named nonsense syllables briefly presented to either the left or right visual field (LVF and RVF, respectively). Experiment 2 compared complete versus no overlap by using the same verbal memory load combined with a laterally presented same-different judgment task that did not require a spoken response. Decrements from single-task performance were always more severe when the visual field task stimulus was presented to the RVF. Further, subjects in Experiment 1 were able to trade performance between tasks on both LVF and RVF trials because there was always at least some overlap in left hemisphere demand. In Experiment 2, performance trade-offs were observed on RVF (complete overlap) trials, but not on LVF trials, where no overlap in demand existed. These results contradict a single-capacity model, but they support the idea that the hemispheres' resource supplies are independent and have implications for both cerebral specialization and divided attention issues.

Attention↗
PubMed2004

Patterns of morbidity and rehospitalisation following spinal cord injury.

STUDY DESIGN: Longitudinal, descriptive design. OBJECTIVES: The aim of this study was to investigate the frequency, cause and duration of rehospitalisations in individuals with spinal cord injury (SCI) living in the community. SETTING: Australian spinal cord injury unit in collaboration with State Health Department. METHODS: A data set was created by linking records from the NSW Department of Health Inpatient Statistics Collection between 1989-1990 and 1999-2000 with data from the Royal North Shore Hospital (RNSH) Spinal Cord Injuries Database using probabilistic record linkage techniques. Records excluded were nontraumatic injuries, age <16 years, spinal column injury without neurological deficit, full recovery (ASIA Grade E) and index admission not at RNSH. Descriptive statistics and time to readmission using survival analysis, stratified by ASIA impairment grade, were calculated. RESULTS: Over the 10-year period, 253 persons (58.6%) required one or more spinal-related readmissions, accounting for 977 rehospitalisations and 15,127 bed-days (average length of stay (ALOS) 15.5 days; median 5 days). The most frequent causes for rehospitalisation were genitourinary (24.1% of readmissions), gastrointestinal (11.0%), further rehabilitation (11.0%), skin-related (8.9%), musculoskeletal (8.6%) and psychiatric disorders (6.8%). Pressure sores accounted for only 6.6% of all readmissions, however, contributed a disproportionate number of bed-days (27.9%), with an ALOS of 65.9 (median 49) days and over 50% of readmissions (33 out of 64) occurred in only nine individuals aged under 30 years. Age, level and completeness of neurological impairment, all influenced differential rates of readmission depending on the type of complication. Overall rehospitalisation rates were high in the first 4 years after initial treatment episode, averaging 0.64 readmissions (12.6 bed-days) per person at risk in the first year and fluctuating between 0.52 and 0.61 readmissions (5.1-8.3 bed-days) per person at risk per year between the second to fourth years, before trending downwards to reach 0.35 readmissions (2.0 bed-days) as 10th year approaches. Time to readmission was influenced by degree of impairment, with significantly fewer people readmitted for ASIA D (43.2%) versus ASIA A, B and C (55.2-67.0%) impairments (P<0.0001). The mean duration to first readmission was 46 months overall, however, differed significantly between persons with ASIA A-C impairments (26-36 months) and ASIA D impairment (60 months). CONCLUSION: Identifying rates, causes and patterns of morbidity is important for future resource allocation and targeting preventative measures. For instance, the late complication of pressure sores in a small subgroup of young males, consuming disproportionately large resources, warrants further research to better understand the complex psychosocial and environmental factors involved and to develop effective countermeasures.

Adolescent↗
PubMed2006

Evidence-based guidelines, time-based health outcomes, and the Matthew effect.

BACKGROUND: Cardiovascular risk management guidelines are 'risk based'; health economists' practice is 'time based'. The 'medical' risk-based allocation model maximises numbers of deaths prevented by targeting subjects at high risk, for example, elderly and smokers. The time-based model maximises numbers of life years gained by treating the young and non-smokers, or 'the one who has will be given more' (Matthew 25:29). We explored practical consequences of risk- or time-based allocation. METHODS: We used epidemiological modelling to generate semi-quantitative scenarios comparing the distributional effects of allocating a fixed number of prescriptions of a (hypothetical) preventive cardiovascular drug ('CVStop') either to avert the maximum number of deaths (risk-based) or to save the maximum number of life years (time based) in the male Dutch population. We subsequently asked 123 Dutch guideline developers which distribution they preferred. RESULTS: Time- and risk-based allocations resulted in different distributions of the drug across the population. There were also differences in absolute numbers of life years gained and deaths averted, and in the distribution of these across the population. For example, risk-based allocation of 'CVStop' resulted in preferential treatment of elderly, leading to more deaths averted (mostly among 70 and above) but fewer life years gained, if compared with time-based allocation. The guideline developers experienced the choice dilemmas as difficult. No priority choice was dominant among the respondents. CONCLUSION: In evidence-based resource allocation the choice to save time or to avert deaths may introduce moral choices because of the various origins of increased disease risk. Evidence-based guideline development inevitably has moral implications.

Adult↗
PubMedDate not supplied

Corporate redemption and the seven deadly sins.

Competitive purgatory is the sorry state of too many formerly proud U.S. corporations. They are languishing from the devastating effects of seven familiar sins: inconsistent product quality; slow response to the marketplace; lack of innovative, competitive products; uncompetitive cost structure; inadequate employee involvement; unresponsive customer service; and inefficient resource allocation. To make matters worse, the maladies are mostly management-induced, and the remedies most managers are employing-shifting strategy, reallocating resources, focusing on operations--are proving ineffective. The cures don't address the cause of the disease: negative, risk-averse, bureaucratic work environments that flourished in decades of easy growth but today are undermining competitive performance. What's needed is a total reinvention of the soft side of the organization to produce a work environment that stresses speed, Spartanism, innovation, and marketplace focus. First, top managers must decide what their company stands for and convince their employees of this uniqueness. Second, they must set standards that drive their business to worldclass levels and be tough about enforcing and raising them. Third, they must push constantly to ensure that enough innovations take place to change the company's future significantly. Three other factors are crucial: the right talent, an effective reward system, and CEOs who can drive the desired changes personally. Creating a dynamic work environment is not easy: it takes perseverance, flexibility, and commitment. But these efforts will pay off: how people tackle problems, work together, and think about their jobs are the activities that make a company great.

Administrative Personnel↗
PubMed1994

POHEM--a framework for understanding and modelling the health of human populations.

A variety of developments have come together to serve as both an impetus to and foundation for the development of a new POpulation HEalth Model (POHEM) at Statistics Canada. Part of the impetus is statistical and derives from weaknesses in Canada's health statistics programme--particularly the lack of balance between information on health outcomes and health care resource consumption, and the absence of a coherent statistical structure. The other major impetus is the need for rational processes for managing and allocating resources to improve the health of Canadians. The foundation for the development of this model has come from the revolution in computing. Dramatic improvements have opened up new methodological opportunities, particularly sophisticated simulation modelling and detailed analyses of large volumes of microdata. POHEM is designed to build on these increasingly powerful methods in order to meet health statistical and policy needs. At this time, POHEM is like a partially-completed building. This article reviews its motivation, the overall architectural plan, and the portion of the structure already completed. A major portion of POHEM is devoted to the explicit modelling of chronic disease processes, using monte carlo microsimulation methods. The article concludes with illustrations of a few recent applications, focusing on the joint patterns of smoking, cholesterol and heart disease, osteoarthritis and lung cancer morbidity. While POHEM has been developed in a Canadian context, work is under way to create a version that can be used in other countries.

Adolescent↗