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PubMed2005

The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care.

The Veterans Health Administration is the United States' largest integrated health system. Once disparaged as a bureaucracy providing mediocre care, the Department of Veterans Affairs (VA) reinvented itself during the past decade through a policy shift mandating structural and organizational change, rationalization of resource allocation, explicit measurement and accountability for quality and value, and development of an information infrastructure supporting the needs of patients, clinicians, and administrators. Today, the VA is recognized for leadership in clinical informatics and performance improvement, cares for more patients with proportionally fewer resources, and sets national benchmarks in patient satisfaction and for 18 indicators of quality in disease prevention and treatment.

Cooperative Behavior↗

PubMed2004

The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care.

Delivery of Health Care, Integrated↗

PubMed1992

Court in the slips.

Judges are only now coming to terms with the implications of resource allocation for medical negligence cases. But, warns John Tingle, managers should keep a close eye on how the law develops case by case.

Health Care Rationing↗

PubMed2003

Cost and cost-effectiveness of HIV/AIDS prevention strategies in developing countries: is there an evidence base?

Many donors and countries are striving to respond to the HIV/AIDS epidemic by implementing prevention programmes. However, the resources available for providing these activities relative to needs are limited. Hence, decision-makers must choose among various types of interventions. Cost information, both measures of cost and cost-effectiveness, serves as a critical input into the processes of setting priorities and allocating resources efficiently. This paper reviews the cost and cost-effectiveness evidence base of HIV/AIDS prevention programmes in low- and middle-income countries (LMICs). None of the studies found have complete cost data for a full range of HIV/AIDS prevention programmes in any one country. However, the range of studies highlight the relative emphasis of different types of HIV/AIDS prevention strategies by region, reflecting the various modes of transmission and hence, to a certain extent, the stage of the epidemic. The costing methods applied and results obtained in this review give rise to questions of reliability, validity and transparency. First, not all of the studies report the methods used to calculate the costs, and/or do not provide all the necessary data inputs such that recalculation of the results is possible. Secondly, methods that are documented vary widely, rendering different studies, even within the same country and programme setting, largely incomparable. Finally, even with consistent and replicable measurement, the results as presented are generally not comparable because of the lack of a common outcome measure. Therefore, the extent to which the available cost and cost-effectiveness evidence base on HIV/AIDS prevention strategies can provide guidance to decision-makers is limited, and there is an urgent need for the generation of this knowledge for planning and decision-making.

AIDS Serodiagnosis↗

PubMed2006

Admission physiology criteria after injury on the battlefield predict medical resource utilization and patient mortality.

BACKGROUND: Medical resources and resource allocation including operating room and blood utilization are of prime importance in the modern combat environment. We hypothesized that easily measurable admission physiologic criteria and injury site as well as injury severity calculated after diagnostic evaluation or surgical intervention, would be strongly correlated with resource utilization and in theater mortality outcomes. METHODS: We retrospectively reviewed the Joint Theater Trauma Registry for all battlefield casualties presenting to surgical component facilities during Operation Iraqi Freedom from January to July 2004. Data were collected from the composite population of 1,127 battlefield casualty patients with respect to demographics, mechanism, presentation physiology (blood pressure, heart rate, temperature), base deficit, admission hematocrit, Glasgow Coma Score (GCS), Injury Severity Score (ISS), operating room utilization, blood transfusion, and mortality. Univariate and multivariate analyses were conducted to determine the degree to which admission physiology and injury severity correlated with blood utilization, necessity for operation, and acute mortality. RESULTS: Univariate analysis demonstrated a significant (p < 0.05) association between hypothermia (T < 34 degrees C) and the subsequent requirement for operation and mortality. In addition, the outcome variable total blood product utilization was significantly correlated with base deficit (r = 0.61), admission hematocrit (r = 0.51), temperature (r = 0.47), and ISS (r = 0.54). Using multiple logistic regression techniques, blood pressure, GCS, and ISS together demonstrated a significant association (p < 0.05) with mortality (area under ROC curve = 95%). Multiple linear regression established that blood pressure, heart rate, temperature, hematocrit, and ISS had a collective significant effect (p < 0.05) on total blood product utilization explaining 67% of the variance in this outcome variable. CONCLUSION: Admission physiology and injury characteristics demonstrate a strong capacity to predict resource utilization in the contemporary battlefield environment. In the future, such predictive yield could potentially have significant implications for triage and medical logistics in the resource constrained environment of war and potentially in mass casualty and disaster incidents in the civilian trauma setting which will likely have mechanistic similarity with war related injury.

Blood Pressure↗

PubMed1991

Politics, power and poverty: health for all in 2000 in the Third World?

Health for All by 2000 could become a reality in the Third World countries. On present resource allocation, medical professional and political patterns and trends that is unlikely to happen in more than a few countries. For it to happen requires basic priority shifts to universal access primary health care (including preventative). The main obstacles to such a shift are not absolute resource constraints but medical professional conservatism together with its interaction with elite interests and with political priorities based partly on perceived demand and partly on (largely medical) professional advice. These obstacles are surmountable-as illustrated by divergent performances among countries--but only if education, promotion, efficiency in terms of lives saved and healthy years gained, community participation and political activism for Health for All are more carefully analytically based and pursued more seriously and widely than they have been to date.

Developing Countries↗

PubMed1999

The application of the continuum of care model in the re-configuration of nutrition and dietetics services.

The continuum of health care model can be used to improve service delivery. Within a hospital setting, finite resources are available. Service gaps must be identified, priorities established and resources re-distributed to meet these gaps. Using Continuous Quality Improvement (CQI) tools, barriers to change were identified and a plan for improvement was formulated. Areas receiving disproportionate resources were identified and a more even resource allocation adopted. In an illustration of the success of strategic change, core services were not only maintained but also showed improved efficiency. The Department of Nutrition and Dietetics at Wollongong and Port Kembla Hospitals achieved an increase in dietetic services through a reorientation of current resources.

Continuity of Patient Care↗

PubMed1997

A pilot study of the cost of educating undergraduate medical students at Virginia Commonwealth University.

PURPOSE: To develop a model isolating the annual per-student cost of, and the fund sources for, educating undergraduate medical students at the Virginia Commonwealth University Medical College of Virginia School of Medicine. METHOD: For 1994-95, hours that faculty spent in direct scheduled contact with students and time that students spent in direct scheduled contact with faculty were inventoried. Student, faculty, and resident contact hours for clinical clerkships and electives were estimated. Faculty contact hours and average faculty workload profiles were used to compute the number of full-time-equivalent faculty positions required to deliver the undergraduate medical curriculum. Support staff and operating budget requirements were based on the number of required faculty, and actual salary averages were used to compute faculty and staff costs. Other institutional costs that indirectly support undergraduate medical education were estimated. Using faculty contact hours and actual cost data, fund sources that support undergraduate medical education were identified. RESULTS: Medical school faculty spent more than 89,000 scheduled hours teaching 674 undergraduate medical students. The faculty-student ratio was 1:3.35. Residents spent nearly 79,000 hours training undergraduate medical students. The total annual cost of undergraduate medical education was $69,992 per student. State funds contributed less than a third of the required financial resources; faculty clinical practice funds provided nearly half. CONCLUSION: Although there are inherent complexities, isolating the cost and fund sources of undergraduate medical education is an essential first step toward providing categorical funding. The model developed during the study provides a basis for assigning costs, allocating resources among instructional programs, and predicting incremental costs (or savings) and revenue requirements. The model may be of use to other medical schools contemplating new strategies for financing undergraduate medical education.

Costs and Cost Analysis↗

PubMed2004

Predicting geographical variations in behavioural risk factors: an analysis of physical and mental healthy days.

STUDY OBJECTIVES: To determine the validity of physical and mental unhealthy days as summary measures for county health status and to forward a method for examining county level health trends using a single year of data from the Behavioral Risk Factor Surveillance System (BRFSS). DESIGN: The study analysed geographical variation in physical and mental unhealthy days at the state and county level using the 2000 BRFSS. Whereas state level analyses used individual level data, this research conducted multilevel regression analysis using county level data as independent variables and individual level reports of physical and mental unhealthy days as dependent variables. SETTING: Population based samples of non-institutionalised civilian adult residents from each of the 50 states and the District of Columbia in the United States. MAIN RESULTS: Socioeconomic variables predicted similar mean numbers of physical and mental unhealthy days at both the state and county level, validating the county level analyses. County level disability rates were strongly associated with county mean unhealthy days. Using the regression method we forward, it is possible to analyse county level trends using a single year of BRFSS data. CONCLUSIONS: Physical and mental unhealthy days may be used as valid summary measures of county health status. Regression models may be used to assist local decision makers in assessing the needs of their communities and may be used to improve health resource allocation within states.

Adolescent↗

PubMed1997

Guidelines for pharmacoeconomic studies. Recommendations from the panel on cost effectiveness in health and medicine. Panel on cost Effectiveness in Health and Medicine.

This article reports the recommendations of the Panel on Cost Effectiveness in Health and Medicine, sponsored by the US Public Health Service, on standardised methods for conducting cost-effectiveness analyses. Although not expressly directed at analyses of pharmaceutical agents, the Panel's recommendations are relevant to pharmacoeconomic studies. The Panel outlines a 'Reference Case' set of methodological practices to improve quality and comparability of analyses. Designed for studies that inform resource-allocation decisions, the Reference Case includes recommendations for study framing and scope, components of the numerator and denominator of cost-effectiveness ratios, discounting, handling uncertainty and reporting. The Reference Case analysis is conducted from the societal perspective, and includes all effects of interventions on resource use and health. Resource use includes 'time' resources, such as for caregiving or undergoing an intervention. The quality-adjusted life-year (QALY) is the common measure of health effect across Reference Case studies. Although the Panel does not endorse a measure for obtaining quality-of-life weights, several recommendations address the QALY. The Panel recommends a 3% discount rate for costs and health effects. Pharmacoeconomic studies have burgeoned in recent years. The Reference Case analysis will improve study quality and usability, and permit comparison of pharmaceuticals with other health interventions.

Cost-Benefit Analysis↗

PubMed1993

Starting a hospice program--a financial perspective.

Questions of handling risk, cost reporting, and allocating resources must be answered before a home care agency can consider itself financially prepared. Careful planning will ensure a successful future.

Accounting↗

PubMed1980

RAWP: the honeymoon is over.

The Rawp honeymoon is over, the Government has seen to that. Nick Davidson asks some questions about the last couple of years of resource allocation and considers the effects of the new austerity on Sunderland, one of the biggest Rawp gaining areas, if such things still exist.

England↗

PubMed1993

[Economic analysis and public health. Why does one need economic evaluation applied to diabetes? What methods does one choose: cost effectiveness, cost utility, cost benefit? Are such studies useful in terms of public health?].

The application of economic methods to public health is relatively recent and linked to the context of economic crisis: cooperation between medical doctors is to day in process. The main objective of health economics is the optimization of health care by improving resources allocation to take care of the patients. So, in France, the health system budget, 573 billions, represents 8.3% of the GNP; this percentage is one of the highest of Europe. Can such a growing rate decrease or are we going towards rationing of health system resources? In this context, economic analysis applied to diabetes uses mainly evaluation methods: cost-effectiveness, cost-utility, cost-benefit. Evaluation always supposes a comparison between medical alternative actions in terms of costs and results. Economic crisis made easier the acceptance of evaluation studies but their development supposes great scientific caution.

Budgets↗

PubMed2006

The economics of adoption and management of alley cropping in Haiti.

The Haitian people are facing serious problems of environmental degradation that threaten the economic livelihoods of many resource-poor farmers. Structures to retard the process of soil loss have been adopted reluctantly and, even when adopted, the management and maintenance have been less than desirable. We evaluate the factors that influence the adoption and management of alley cropping in Haiti. Results of the adoption model show that institutional factors, such as membership in a local peasant organization and training in soil conservation practices, favorably influence adoption. Socio-economic factors such as gender, per capita income, and interaction between education and per capita income also significantly influence adoption of alley cropping in Gaita and Bannate. The management of alley cropping is influenced by demographic, socio-economic, institutional, and physical factors. The relative importance of each factor on the probability of adoption and management of alley cropping varies from one variable to another. The study generates important information for resource allocation in the establishment of alley cropping as a soil conservation structure.

Adolescent↗

PubMed2002

Financial consequences of changes in health care demands related to tobacco consumption in Mexico: information for policy makers.

This paper presents the results from a longitudinal study in which the main purpose was to determine the health-care costs and financial consequences of changes in the health care demands related to tobacco consumption in Mexico. Eleven health interventions were selected to conduct this study and four probabilistic models were developed to forecast the expected changes in the epidemiologic profile of selected diseases. The costing method was based on the identification of case management costs using the instrumentation and consensus techniques, probabilistic models were designed using the Box-Jenkins technique and allowed us to identify the expected case trends for the 2001-2003 period. The generation of information on case management costs for the selected interventions is a central instrument in the planning of health programs, above all in that which refers to resource allocation by type of demand. On the other hand, the identification of expected cases and the financial consequences allowed us to know the growing trends of the sums required to satisfy health care demands for the period under study. The three types of information are a relevant resource for decision-makers in the production and financing of health services.

Case Management↗

PubMed2003

Proposition: the benefit of cardiac transplantation in stable outpatients with heart failure should be tested in a randomized trial.

Recent data suggest that cardiac transplantation is associated with a survival benefit only in patients at high risk for dying of advanced heart failure without this procedure. To test the hypothesis that survival and quality of life advantages associated with cardiac transplantation exist in stable outpatients, a 3-stage approach is proposed: 1). to establish a database within the International Society for Heart and Lung Transplantation/United Network for Organ Sharing/Eurotransplant infrastructure that will provide an estimate of the survival benefit of heart transplantation in various heart failure risk strata by prospectively following cohorts of patients listed for heart transplantation; 2). to organize an international consensus conference that will define, based on the review of the Stage 1 data, the feasibility of a prospective randomized trial; and 3). pending consensus, to perform a clinical trial, perhaps with an augmented, randomized design that allocates cardiac transplantation to all patients at high risk for dying of heart failure while randomizing patients at low risk to either conventional treatment or cardiac transplantation. Generating such scientific evidence is important in light of today's donor organ crisis and the associated difficulties of equitable resource allocation.

Cohort Studies↗

PubMed1999

Assessment of primary health care access status: an analytic technique for decision making.

Access to health care is an issue that has caught the attention of health care providers, policy formulators, and policy analysts, with particular emphasis on access to primary care, which affords all people a viable portal into the health care system. This paper proposes an analytical approach to the assessment of relative primary care access status, measured as the capability to deliver basic primary care services within specific geographic civil areas, or parishes, within the state of Louisiana. An additive multiattribute utility method is employed to develop a scoring system to rank parishes according to a primary care access, or health system capability, numerical score. Routinely collected parameters are used to measure each parish's current capability to provide primary care services. These parameters include demographic, mortality, morbidity, and resource data. A group of experts was used to give weight to each parish's parameter values, resulting in a relative score for each. Thus, parishes (or other geographic areas) can be ranked according to their primary care access status. This information can then be used to allocate resources, to distribute funds for health care services, and to guide policy formulation and implementation.

Community Health Planning↗

PubMed1995

Resource scarcity and outcome conflict in time-sharing performance.

The efficacy of the resource-scarcity and outcome-conflict views in explaining dual-task interference was examined. A discrete-continuous task pair was purposely chosen to allow fine-grained analysis of time-shared performance. The relative priority of the dual task was manipulated by a secondary task technique to test for performance tradeoff that would be indicative of resource allocation. The temporal predictability of the discrete stimuli was manipulated to examine possible strategic avoidance of interference. The moment-by-moment data did not reveal any evidence for a switching strategy. It was concluded that the intricate interference patterns could be more easily interpreted within the resource framework than within the outcome-conflict framework.

Adolescent↗