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PubMed1997

How and where the education dollar is spent.

Locally elected school boards have the authority and responsibility to decide how school budgets will be spent. In doing so, however, they must balance multiple funding restrictions and competing priorities. Despite great variance in local circumstances, most school districts have remarkably similar spending patterns, generally allocating from 60% to 63% of their budget to instruction and dividing the remainder among student services such as health services, counseling, and speech therapy; administration; building operation and maintenance; and food services and transportation. Polls show that many districts are attempting to delegate more decisions over resource allocation to the school site level. Research is just beginning to show what aspects of school site decision making are associated with improved teaching and learning.

Adolescent↗
PubMed1985

Physiologic assessment of surgical diagnosis-related groups.

Although (diagnostic related groups) DRGs were originally devised as a research instrument for the evaluation of medical resource allocation, no studies have been reported that compare the actual physiologic status of patients with DRG classification. At the Westchester Medical Center, a University tertiary referral center, 100 consecutive high-risk elective surgical patients entered a preoperative intensive care unit for a prospective analysis of physiologic assessment, resource utilization, DRG classification, and outcome. Swan-Ganz catheters inserted 1 or 2 days before surgery were used to compute physiologic profiles and stage according to previously published criteria. Risk was determined by age, associated conditions, and magnitude of the proposed operation. There were no patients in stage 1; 55% in stage 2; 41% in stage 3; and 4% in stage 4, which accounted for three of the four total deaths. The 41% of patients over age 70 all had DRG comorbidity factors, but none died. All in stages 3 and 4 had comorbidity factors, as did 87% in stage 2. In 53% of the patients, the physiologic profile provided data necessary for preoperative "fine tuning"; in 37%, for volume expansion; in 23%, for inotropic therapy; and in 17%, for pulmonary therapy. Reoperation was required in 17% and contributed to the long average length of stay (LOS) of 24.5 days. In spite of case severity and comorbidity factors, LOS in the postoperative ICU was only 3 days. There were no significant differences in patients with cancer DRGs. Significant differences between stages 2 and 3 were found for pulmonary wedge pressure, right ventricular stroke work, pulmonary vascular resistance, and pulmonary shunt fraction. The 4% who died all had advanced liver disease. Although the DRG system as set up by the Health Care Financing Administration (HCFA) correctly predicts that age and comorbidity factors lead to increased utilization of resources, the extent to which they underestimate the increased needs of these patients will lead to financial disaster. Compensation for comorbidity factors and advanced age are not cumulative, but patients over 70 had an average of 2.5 comorbidity factors and required an average 26.5 days hospitalization. DRGs allowed only 15% extra reimbursement for these complex cases. High-risk, referred surgical patients are much sicker than they appear to the DRG system, and in all 100 cases compensation was grossly inadequate.

Age Factors↗
PubMed2007

Analysis of multidisciplinary lung cancer practice.

BACKGROUND: The aim of this study was to describe the activity of a lung cancer multidisciplinary clinic (MDC) and examine whether this model of clinical practice results in adherence to best-practice guidelines. METHODS: Prospective analysis of demographic and clinical data in 431 patients referred to a lung cancer MDC for the management of known or suspected thoracic malignancy. Adherence was documented to clinically relevant guideline recommendations concerning timely and evidence-based lung cancer management. RESULTS: Of 431 patients, 257 were diagnosed with primary lung cancer, mean age 68 years, 70% men and 90% current smokers or ex-smokers. Only 21% were referred with known malignancy and 28% were asymptomatic. Overall, 51% had stages I and II non-small-cell lung cancer, with this bias towards early-stage disease greatest in patients from rural areas. Histological confirmation of lung cancer was obtained in 92%. There was a high rate of adherence to international guideline recommendations concerning timely lung cancer diagnosis, staging and treatment implementation. Similarly, there was adherence to selected key evidence based recommendations for lung cancer management contained in national guidelines. CONCLUSION: Within a MDC, patients receive timely diagnosis, staging and treatment according to evidence-based guideline recommendations. The high proportion of patients receiving active treatment has implications for resource allocation. There is a referral bias towards patients with early non-small-cell lung cancer, particularly in rural patients, suggesting that further education about advances in metastatic lung cancer management is required. This study would support the establishment of regional lung cancer services with links to fully resourced MDC.

Adult↗
PubMed1990

Pelvic inflammatory disease and related disorders; novel observations.

All efforts and economic resources allocated to different means to restore possibilities for women with obligated and damaged fallopian tubes to conceive and of involuntary childless couples to adopt children stress the disability of persons with such sequelae of pelvic inflammatory disease (PID). In contrast, preventive measures have so far obtained much less resources. At present, the number of PID cases in Sweden that become hospitalized has markedly decreased during recent years. This decrease preceded that of the number of diagnosed cases of gonorrhoea but preceded the level off and recent slight decrease of chlamydial cases seen in Sweden. Whether the decrease of PID cases represent a true decrease or not is not known. There has obviously been a shift to a greater proportion of non-gonococcal (chlamydial cases) versus gonococcal PID cases in Sweden. The former type of cases may generally have a milder clinical course which might mean the PID cases nowadays more often are low symptomatic or even asymptomatic and will thereby often be treated in ambulatory practice or not all all. The use of oral contraceptives may protect against ascending infection by chlamydiae, but not against gonococci. This may have a marked influence on the epidemiology of PID in Sweden. There are evidence of chronic tubal chlamydial infection often passing undiagnosed and that the diagnosis is first established in conjunction with ectopic pregnancy or infertility investigation. Ectopic pregnancy as a sequelae of chlamydial salpingitis is on its increase in most countries, including Sweden. The incidence of ectopic pregnancy generally follows more than 5 years after a chlamydial infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Contraception↗
PubMed2005

Evidence-based medicine: can it be applied to stimulation of erythropoiesis for patients with malignancy?

Health care decision-making is affected by the values of patients and providers, available resources, and information substantiating effectiveness (or efficacy) of a particular therapy. A number of factors contribute to our growing need for evidence-based decision-making. Our aging population generally requires greater medical attention in a system with limited resources devoted to health care. Technologic advances have produced an ever-expanding range of expensive treatment options. Patients, and their providers, expect early access to these emerging therapies. Patients also expect care of universally high quality, even as respected authorities suggest there exists a substantial gap between these expectations and the care actually delivered. Evidence based decision-making offers the opportunity to use medical evidence to reduce uncertainty regarding research information and improve the value of health care delivered. Evidence based medicine (EBM) is the 'conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.' It combines clinical judgment and experience, best available scientific evidence, and patient preferences to improve medical decision-making. Though often incorrectly maligned as cookbook medicine that dismisses any research findings that do not derive from randomized clinical trials, it provides clinicians, health care systems, payers and policymakers with tools to appropriately evaluate the research evidence that substantiates various therapies and integrate that evidence with clinical expertise and patient's values in medical decision-making. The erythropoietic stimulants epoetin and darbepoetin have shown efficacy in improving anemia of chronic renal failure and following chemotherapy for many patients. In some studies these agents have also improved health-related quality of life. Unfortunately, only 60-80% of patients treated with erythropoietic stimulants respond, and like many emerging therapies, they are quite expensive. Likewise, there is substantial variation in their usage, suggesting both inappropriate use and non-usage. Reimbursement coverage decisions for erythropoietic stimulants have been hampered by the lack of high-quality evidence in certain applications. Physicians are increasingly turning to evidence-based medicine resources (guidelines, systematic reviews) to inform their decisions regarding application of new therapies. Evidence-based medicine offers health care decision-makers the opportunity for quality improvement, efficient resource allocation and utilization, informed policy-making and reimbursement, and identification of future research priorities. Judicious use of erythropoietic stimulants guided by evidence-based decision-making should ensure treatment of patients who can be reasonably expected to benefit with appropriate dose regimens, while preserving valuable health care resources in those situations where patients are not expected to derive significant health care benefit.

Anemia↗
PubMed1982

Commitment of national resources to health promotion: the Canadian experience.

The article "Federal Initiatives in Health Education in Canada" which was featured in the first issue of Hygie reviewed the historical developments and the federal-provincial co-operative efforts in health education. It described the events and aspirations leading to the establishment, in 1978, of the focal point on health promotion. The current paper by R.A. Draper, Director General of Health Promotion in the Department of National Health and Welfare, addresses itself to the modes of resource allocation and policy development. It outlines the programmatic considerations of health promotion which reflect the current status of health education and promotion in Canada.

Canada↗
PubMedDate not supplied

Decision-making and nurse case management: a philosophical perspective.

Decision-making related to resource allocation in home care case management practice is addressed from the unique perspective of nursing. The case management process stipulates the adherence to both client-centered and system-centered goals. Issues that emerge from this process include the ethical dilemma of deciding the equitable and fair distribution of resources related to the provision of appropriate levels of service; economic factors as they relate to limited financial resources; and the variance among case managers in their decision-making. Moderate realism, as compared to critical and feminist theory, provides a philosophical perspective that allows a practical interpretation of these issues.

Case Management↗
PubMedDate not supplied

Increasing the effectiveness of resource deployment in healthcare organizations.

This article suggests ways to enhance the effectiveness with which healthcare organizations deploy their resources. Specifically, the article: (1) reviews research findings from the academic literature that managers often continue, or even increase, resource allocation to unprofitable courses of action; (2) reports the results of a case study with hospital administrations that suggests that this tendency may exist in healthcare organizations; and (3) suggests ways for healthcare organizations to control the occurrence of such suboptimal actions, thereby increasing the effectiveness and timeliness of their resource deployment.

Attitude of Health Personnel↗
PubMed1995

The managerial revolution: medicine as a business.

Medicine and management should be more closely integrated not just at the level of health policy and health services management but also in matters of professional education and training. Learning is a continuous process from entering medical school to retirement and should reflect the transition from learning shaped by the curriculum to learning driven by the needs of the qualified professional in a career service post. The senior clinician does much more than practise clinically. He or she is a leader, a manager, a resource allocator, a teacher and team player. In these roles the values and priorities of the professional and the organization will not always coincide. In postgraduate training and in continuing medical education more joint activity should be developed around 'medicine for non-medical managers' and 'management for doctors'. Much of this shared learning and development will be local and problem-based around local issues of quality, resources and priorities. However, the 'regional' postgraduate dean will play an increasingly pivotal role in maintaining the balance between the needs of the individual and the organization. To achieve this objective of closer integration postgraduate medical education funding should be brought together under a national finance levy against purchasers and allocated through devolved budgets managed by 'regional' postgraduate deans against explicit performance criteria agreed between the professional organizations, universities and health services management.

Capital Financing↗
PubMed1991

Nursing aspects of infection control in developing countries.

The quality of the infection control programme in developing countries is determined by the resource allocation to the health sector and the health care delivery system. These depend to a great extent on the socio-economic development of the country. Morbidity and mortality from communicable infections, such as diarrhoeal diseases and malaria are high. There is often an irregular water and electricity supply. Essential material resources, e.g. paper towels, gowns, gloves, masks and disinfectants may not be available and some disposable materials have to be re-used. Most hospitals have no infection control programme due to the lack of awareness of the problem or absence of trained personnel in infection control practices. Developing countries differ in many ways from each other, often having dissimilar cultures and languages and state of socio-economic development. Solutions will emerge only if there is co-operation between countries and provision of assistance, where appropriate, from wealthier countries.

Cross Infection↗
PubMedDate not supplied

Treatment costs, equilibrium, and the allocation of patients to therapy alternatives.

This paper addresses the problem of increasing costs (or decreasing returns) in the treatment of patients within health care systems. We examine the implications of such a situation for (1) the allocation of patients to alternative drug therapies within a disease area; and (2) the proportions of patients being treated within the disease area to the total patient population as a function of the equilibrium conditions for maximized health care outcomes, given alternative assumptions about the existence of budget constraints on the resources allocated to the disease area. The reason for considering these issues (in this case, from a purely theoretical perspective) is that such a model and the assumptions that drive it stand in marked contrast to those underlying (implicitly if not explicitly) the traditional approach to cost-effectiveness modeling. In traditional cost-effectiveness analysis, the assumption is that costs and outcomes exhibit constant returns to scale and that the process of patient selection and the characteristics of the treating population need not be taken into account. However, our analysis demonstrates that once the assumption of constant returns in abandoned, any assessment of the net impact of therapeutic interventions can be made only within an equilibrium, or comparative static, framework that is subject to budget constraints and in which the cost functions that drive patterns of switching between therapies are specified. Under such conditions, the traditional, clinical-trial-based notion of cost-effectiveness loses all meaning.

Complementary Therapies↗
PubMed1999

Reforming health service delivery at district level in Ghana: the perspective of a district medical officer.

Many countries in sub-Saharan Africa face the problem of organizing health service delivery in a manner that provides adequate quality and coverage of health care to their populations against a background of economic recession and limited resources. In response to these challenges, different governments, including that of Ghana, have been considering or are in the process of implementing varying degrees of reform in the health sector. This paper examines aspects of health services delivery, and trends in utilization and coverage, using routine data over time in the Dangme West district of the Greater Accra region of Ghana, from the perspective of a district health manager. Specific interventions through which health services delivery and utilization at district level could be improved are suggested. Suggestions include raising awareness among care providers and health managers that increased resource availability is only a success in so far as it leads to improvements in coverage, utilization and quality; and developing indicators of performance which assess and reward use of resources at the local level to improve coverage, utilization and quality. Also needed are more flexibility in Central Government regulations for resource allocation and use; integration of service delivery at district level with more decentralized planning to make services better responsive to local needs; changes in basic and inservice training strategies; and exploration of how the public and private sectors can effectively collaborate to achieve maximum coverage and quality of care within available resources.

Developing Countries↗
PubMed1987

An ecological approach to defining discharge planning in social work.

Ambiguities in definitions of discharge planning hinder clarification of the social work role. An ecological approach defines discharge planning as interprofessional, client-organization, and often interorganizational activity, focused on ensuring high quality care in a patient's transition from hospital to community. The resourcing, allocation and integration of its component tasks throughout the health-care continuum are influenced by significant and interacting environmental variables requiring further study: the strength of discharge planning policy; the point of access for planning; the patient's state and personal network; the nature of the treatment organization and its resource network.

Family↗
PubMed1993

American College of Epidemiology 10th annual scientific meeting. Disparities in health between minorities and nonminorities. Recommendations for future research and action.

As a nation, we must accept and appreciate the fact of the racial and cultural diversity that characterizes America. Such diversity dictates that fundamental approaches and solutions to social problems, including health, need to be specific to local areas. From addressing health problems, the least controversial of social challenges, a degree of mutual respect can evolve that permits other issues to be addressed as well. Resolving health problems will require a coordinated effort of local, city, state and federal resources, both medical and non-medical. In addressing such problems, three important principles need to be embraced: 1) the development of a surveillance system to measure the problem and assess progress in terms of ultimate outcomes; 2) the continuing use of surveillance data to assess and modify strategy and to allocate resources as needed; and 3) the need in health programs in particular to assign far higher priority to "consumer satisfaction."

Consumer Behavior↗
PubMed1983

Quality of life as the criterion for need assessment and community psychology.

A "QOL-Contribution" model for resource allocation decisions is proposed that integrates concepts and values from community psychology, need assessment, and quality of life (QOL) studies. QOL is taken as the criterion for establishing the goodness-of-fit between a population and its environment. It is assumed that the characteristics of a given human group interact with the resources and the stressors of its environment, with its level of QOL as the result. The utility and the implications of the model for resource decisions are demonstrated with data from a statewide need assessment. In this application, different life domains, and different program targets within life domains, are prioritized according to their relative contributions to QOL. The findings for mental health and employment illustrate the specificity of the model's application. The model is then restated as the general task, and a unifying theme, for community psychology.

Adult↗
PubMedDate not supplied

[Equity and geographic distribution of financial resources in health systems].

This study focuses on equity in health and specifically the geographic distribution of financial resources. The author reviews the main contemporary theories of social justice and discusses the concept of equity in general and specifically in the health field. Based on the discussion of selected international experiences (United Kingdom, Spain, and Italy), the Resource Allocation Working Party (RAWP) formula used in the United Kingdom is identified as the most adequate distributive methodology, sizing the relative needs based on the population's demographic and epidemiological profiles. Finally, the results are presented from a simulation performed for the Brazilian case, showing that a more equitable geographic distribution of financial resources would require a redistribution favoring the States of the North and Northeast. The article concludes by highlighting that a comparison of actual fund outlays by the Ministry of Health in 1994 and the results of the simulation with the RAWP methodology for the Brazilian case show that the principles written into Brazilian legislation were absent from the geographic distribution of financial resources.

Brazil↗
PubMed2006

Construct and criterion validities of the Service Need Assessment Profile (SNAP): a measure of support for people with disabilities.

BACKGROUND: The Service Need Assessment Profile (SNAP) measures individual functional needs in areas of daily living. It produces a support profile, detailing the time allocations for staff support to assist in each area of need. The Supports Intensity Scale (SIS) is a support needs assessment scale designed to provide an objective measure of a person's need for support in medical, behavioural, and life activities. SIS can be used for individualised support planning, clinical judgements regarding support needs, resource allocation and financial planning. The Inventory for Client and Agency Planning (ICAP) assesses adaptive and maladaptive behaviours and gathers additional information to determine type and amount of special assistance that people with disabilities need. METHOD: This study evaluated the construct and criterion validities of SNAP in relation to the SIS and ICAP, using assessment data from 114 individuals with a range of disabilities and levels of severity. RESULTS: Construct and criterion validities were supported for the SNAP by high correlations with SIS, ICAP, and staff estimates of support needs and by its capacity to discriminate between sub-groups in expected ways. CONCLUSIONS: The results provide support for the use of SNAP as a support needs instrument.

Activities of Daily Living↗
PubMed1996

Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgical procedures.

Resource allocation, including manpower and other expenses, have limited the evolution of minimally invasive surgical procedures to provide humanism and to improve surgical care for patients. Robotic enhancement has been proposed as a mechanism to improve the cost-benefit relationship for patients. To this end, we have used the robotic arm enhancement to minimize resource and personnel utilization during minimally invasive procedures. Phase I of our study has included the use of the robotic arm in 24 laparoscopic hernia repairs, cholecystectomies, and nissen fundoplications with the surgeon as a solo surgeon, i.e., the primary surgeon is the only participant in the operative sterile field. The scrub nurse did not participate in the procedures. During this study, there were no technical mishaps, no complications related to the solo surgeon-robotic arm concept, and the operative times were statistically similar to equivalent procedures utilizing multiple personnel. The hernia repair is least complex and most amenable to solo surgery due to the use of only three access ports; cholecystectomy occasionally requires four access ports increasing its complexity to a measurable degree. Nissen fundoplication, however, requires five access ports and proved to be the most complex of the procedures to adapt successfully to solo surgery utilizing robotic arm enhancement. Phase II of our study has involved the use of a combination of technologically complex and sophisticated technology to improve outcomes in complex laparoscopic procedures. The head-mounted display, the robotic arm, and the harmonic scalpel have been used in 140 complex minimally invasive procedures; the procedures were laparoscopic spine surgery (24 cases), laparoscopic gastric surgery (28 cases), and laparoscopic colon resection (88 cases). The use of these sophisticated technologies added safety, improved versatility, and did not increase the length of the operative procedures. The use of multiple technologies had an additive effect on the benefits. There were no experiences in which the technologies contributed to a technical complication or an adverse result for the patients. However, the successful use of these technologies requires an in depth educational experience for the surgeon and for the operating room team. In a further effort to improve efficiency and control of the visual fields during minimally invasive surgery, we have implemented a prototype voice activation, head-directed control, and instrument tracking by robotic arm enhancement in order to control the visual field through computer programming. Prototype voice activation and deactivation also allows instruments to be used in the visual field for the surgical procedure while not being used for tracking of the visual field. Tracking with the instrument utilizing a color-coded tracking system, and the head-directed control system have both been 100% effective in our hands, have not induced errors in technical performance of procedures, and have shortened the time required for performance of specific procedural tasks. Further, this process improves versatility for the surgeon, increases concentration, reduces fatigue and does not interfere with the position of the surgeon. Areas for improvement which have been observed utilizing these techniques are (1) the use of appropriate and consistent voice activation terminology, (2) the proper positioning of the instrument tracking unit in the most appropriate locations on the video screen and on the instrument within the visual field, and (3) the appropriate use of head-directed control of the robotic arm. We have concluded from these experiences that the robotic technology will continue to reduce costs and minimize risk for patients undergoing minimally invasive surgical procedures; moreover, safety, versatility, and diminished use of resources will accrue utilizing the additive benefit of sequential sophisticated technologies requiring a simultaneous educational

Animals↗