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[Health care priorities].

This article describes the STAKES (National Research and Development Centre for Welfare and Health) Priorisation Project which started at the beginning of 1993. The project surveys ethical problems related to welfare and health care resource allocation. It searches for principles which could be applied in setting priorities whether they are aimed at service systems or individuals. A public debate has been instigated on choices, their justification and values which influence them. A conflict arises when medical advances have improved treatment possibilities and the needs have increased, but health care resources have remained on the same level or diminished. The role of nursing is to safeguard the rights of the patients. Now it is more important than ever to base nursing practice on ethical principles.

Consumer Advocacy↗

The morality of efficiency in health care--some uncomfortable implications.

There are some general considerations which have implications for the delivery and finance of health care in all countries, not only Canada and the USA. Beginning with two propositions: that access to health care is a right of citizenship, which should not depend on individual income and wealth; and that the objective of health services is to maximise the impact on the nation's health of the resources available; the paper examines the ethical justification for pursuing efficiency in health care provision. The different meanings of efficiency are discussed in detail, and the use of quantitative indicators of health benefit, such as the QALY, placed in context. It is argued that the determination of health care resource allocations should take account of costs at both the macro planning level and the micro level of the individual doctor-patient relationship. Given the starting points the overall conclusion is that it is ethical to be efficient, since to be inefficient implies failure to achieve the ethical objective of maximising health benefits from available resources.

Canada↗

Trade-offs between flower number and investment to a flower in selfing and outcrossing varieties of Impatiens hypophylla (Balsaminaceae).

Floral resource allocation was compared on a whole-plant basis between two varieties of Impatiens hypophylla that differ in flower size. There were significant negative correlations between flower number and investments to a flower at both the within-population and between-variety levels. In individual flowers, var. hypophylla with larger flowers invested significantly more resources to male and pollinator-attractive functions, whereas investments to female function did not differ between the varieties. In experimental populations placed in the field, pollinators preferred the larger flowers of var. hypophylla even within the same habitat of var. microhypophylla, which has smaller flowers. There was a significant lack of observed heterozygosity only in var. microhypophylla. Thus, the outcrossing variety had more attractive but fewer flowers, while the selfing variety had less attractive but more abundant flowers.

Journal Article↗

Direct and indirect costs in a prospective cohort of patients with pancreatic cancer.

BACKGROUND: Pancreatic cancer is an aggressive cancer with a low survival time. So far, there have been no studies assessing direct and indirect costs in individual patients. AIM: To assess prospectively the cost of illness in patients with pancreatic cancer. METHODS: Patients were consecutively included at first admission to hospital. Sociodemographic factors, medical resource use and employment status were assessed by patient interviews and from medical records in a standardized way. Costs were calculated from the perspectives of the hospital, social insurance and society. Linear regression analyses were used to determine factors associated with costs. RESULTS: A total of 57 patients were admitted with suspected pancreatic cancer. Of these patients, 45 (79%) had pancreatic cancer as final diagnosis, 11 (19%) pancreatitis and one patient cystadenoma. The median survival was 10.9 months in patients with pancreatic cancer. Per month of observation from societal perspective, total costs were 4075 for patients. Costs of hospitalizations were responsible for 75% of total costs. In multivariable analyses, surgery, a lower educational level, younger age, and the prevalence of metastases were significantly associated with higher total costs. CONCLUSIONS: Costs are considerable in patients with pancreatic cancer. Our results may facilitate further economic evaluations and aid health policy-makers in resource allocation.

Absenteeism↗

Biotechnology and ethics in medical education of the new millennium: physician roles and responsibilities.

Although the medical education curriculum varies internationally, we suggest that it is desirable for medical educators to share a universal responsibility to prepare physicians to perform three distinct, yet interrelated professional roles. The first is that of a clinician who has the knowledge and technical skills to care for individual patients, as well as the public. The second role can be viewed as that of an educator, a teacher, or a consultant who has the interpersonal skills and personal qualities to teach, advise and counsel patients and the public about their health and illness, risk factors and healthy lifestyle. The third role is that of a resource manager to enable physicians to care for patients and serve the public not only by drawing on available material assets but also by prudent use of the resources for better serving the most number of people at the least expense without compromising the quality of care. The very nature of the medical profession also obligates medical educators through the world to sensitize medical students and physicians to the ethical responsibilities that are implicit to each of the three aforementioned roles. Although the basic ethical responsibilities of do no harm and confidentiality are universal, certain global changes, such as rapid advancements in biotechnology and resource allocation, are now reshaping medical ethics on every continent. Spawned by the rapid advances in the biomedical sciences, biotechnology is revolutionizing human reproduction, sustaining human life, cloning human beings, and mapping the entire human genetic terrain. These advances imply changes in medical education and formal preparation of physicians in performing their roles as clinicians, educators and resource managers. These biotechnological developments, coupled with the increasing cost of healthcare and maldistribution of resources worldwide, present unprecedented ethical-social challenges that need to be addressed in the education of the physician in the new millennium.

Journal Article↗

Environmental effects on fitness-sets shape and evolutionarily stable strategies.

Most models on the evolution of sex allocation and life-history traits are based on the existence of compensations between these traits, and often consider them as linear. With a simple model of physiological response to richness of the environment, we show that not only can these compensations take many different shapes, but also that this shape varies as a function of the resource level. Consequently, evolutionarily stable strategies (ESSs) calculation can give different results for the same two functions according to resource level. Thus, selection can act in different directions depending on the "quality" of the environment. Moreover, genetic variability in the resource allocation strategies is likely to be shown better in intermediate environments, where the proportions of allocation have the most crucial effect on the phenotype.

Animals↗

PIS and DRGs: coding inaccuracies and their consequences for resource management.

Accurate information is important for the successful implementation of the Resource Management Initiative and the NHS White Paper. A review of 153 joint replacements performed in a three-month period in Leicester showed that 24 per cent of 139 procedures for which medical notes were available had been given incorrect Diagnosis-Related Groupings (DRGs). Of these, 64 per cent could be ascribed to errors in allocating OPCS-3 codes and 36 per cent to errors in converting OPCS-3 codes to DRGs by computer. It is of concern that inaccurate information may in future be used to allocate resources. The resource implications of assiduous quality control of recording, coding and computing is pointed out, and it is suggested that improved classification systems should be assessed for use in the NHS.

Diagnosis-Related Groups↗

Challenges to academic psychiatry.

Economic constraints, effects of retrenchments in federal health policy, and increased competition for resources are challenging all sectors of academic medicine. Departments of psychiatry are at particular risk during this era for reasons including the lack of a sound research and research training base in many psychiatry departments; the small number of students entering the field and implications therein for the availability of residency slots in psychiatry; and patterns of allocating resources within academic medical centers which, combined with biases in reimbursement policy toward cognitively based specialties, threaten the economic strength of psychiatric departments. A conceptual model based on marketing principles is proposed to aid in identifying and capitalizing on the unique strengths of the field.

Academic Medical Centers↗

Are guidelines ethical? Some considerations for general practice.

Guidelines have been promoted in various roles in general practice, e.g. to improve quality of care, to assist patient decision making, and to improve resource allocation. This paper examines these claims using ethical analysis. Guidelines may help general practitioners to act for thegood of their patients and avoid harm; but, on their own, guidelines cannot ensure quality of care or the protection of patients' interests. Patient choice may be limited rather than enhanced by following guideline recommendations. Guidelines contribute to rationing of resources but do not use explicit citeria for this. The ethical implications for guideline use are complex and far-reaching

Cost-Benefit Analysis↗

Press coverage of public expenditure of Master Settlement Agreement funds: how are non-tobacco control related expenditures represented?

OBJECTIVE: To examine newspaper reports of Master Settlement Agreement (MSA) allocation decisions outside of tobacco control, focusing on the arguments being put forth in favour of competing claims on MSA funds. The major aims were to identify newsworthy non-tobacco control areas for which MSA funds have been applied and to examine how non-tobacco control spending has been presented through the US press. DESIGN: A qualitative textual analysis was performed on 94 articles taken from a sample of 322 newspapers over a 12 month period (October 2000 through September 2001) that related to the allocation of MSA funds to non-tobacco control causes. Articles were coded for general content areas of MSA allocation as well as for rhetorical and framing devices employed to explain and justify allocation decisions. MAIN OUTCOME MEASURES: (1) Areas of non-tobacco control allocation; (2) rhetorical devices and framing techniques employed in the articles to discuss the allocation. RESULTS: The analysis identified a wide variety of issues for which MSA funds were being appropriated. Three main frames emerged in relation to justifying or appealing for particular spending decisions: (1) funds should be allocated to the needy and/or the deserving; (2) funds should be spent on state development; (3) funds should be put towards helping the state weather a crisis. Claims for each such issue were made using strategies such as presenting the MSA funds as a "windfall", focusing coverage on the merits of the cause rather than the issue of resource allocation, and stressing links between the particular claim and the stated objectives of the MSA. CONCLUSIONS: Press coverage of MSA non-tobacco control spending suggests that the funds have been quickly formulated as fodder for state spending, rather than to support tobacco control efforts. Thus, caution is required in pursuing settlements with the industry where the objective is better funding for tobacco control efforts, particularly in light of the possibility that press coverage of MSA allocation may actually serve as positive publicity for the tobacco industry.

Health Expenditures↗

Getting the most out of all your customers.

Companies spend billions of dollars on direct marketing, targeting individual customers with ever more accuracy. Yet despite the power of the myriad data-collecting and analytical tools at their disposal, they're still having trouble optimizing their direct-marketing investments. Many marketers try to minimize costs by pursuing only those customers who are cheap to find and cheap to keep. Others try to get the most customers they possibly can and keep all of them for as long as they can. But a customer need not be loyal to be highly profitable, and many loyal customers turn out to be highly unprofitable. Companies can get more out of direct marketing if they see it as a single system for generating profits than if they try to maximize performance measures at each stage of the process. This article describes a tool for doing just that. Called ARPRO (Allocating Resources for Profits), the tool is essentially a complex regression analysis that can estimate the impact of a company's direct-marketing investments on the profitability of its customer pool. With data that companies already gather, the tool can show managers how much to spend on acquisition versus retention and even what percentage of their funds they should allocate to the different direct-marketing channels. Using the model, companies can easily see that even small deviations from the optimal levels of customer profitability are expensive. Applying it to one catalog retailer showed, for instance, that a 10% reduction in marketing costs would lead to a 1.8 million dollar drop in long-term customer profits. Conversely, spending 69% less on marketing would actually increase average customer profitability at one B2B service provider by 42%. What's more, the tool can show that finding the optimal balance between investments in acquisition and retention can be more important than finding the optimum amount to invest overall.

Budgets↗

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program.

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.

Adolescent↗

Reflections on the health budget. A preliminary analysis of the 1974/75 Ministry of Health budget.

This paper describes the 1974/75 Budget, and analysis it in terms of allocations to Medical Care, Public Health and Training functions as well as by allocations to Regions. 80% of the Health Vote goes into Curative or Medical Care, 12% into the Preventive Services, 6% into Trining and the rest to Headquarters. It brings out the great disparities among the Health Care System of the various Regions, and suggests also that the method of the presentation of the Health Budget makes it difficult to understand resource allocations within the Health Sector.

Financing, Government↗

The managerial nature of case management.

Case managers have been viewed as engaging in direct practice, community practice, or both. This article offers a third view: Case managers also engage in the practice of management. Employing Mintzberg's seminal research on chief executive behavior, the authors argue that case managers' work is similarly characterized by brevity, variety, and fragmentation. Case managers perform the 10 roles developed in Mintzberg's original study. These roles are divided into three groups: interpersonal, including figurehead, leader, and liaison; informational, including monitor, disseminator, and spokesperson; and decision-making, including entrepreneur, disturbance handler, resource allocator, and negotiator. Case managers' tasks associated with each role are presented. Considering their work as managerial in nature will help case managers more effectively assist clients in goal achievement.

Health Resources↗

The student diary survey: a method of monitoring hospital-based medical education.

A new system of allocating the Service Increment for Teaching (SIFT) has recently been introduced which, by its nature, encourages universities to be more explicit about their teaching requirements. A detailed study of the quantity of teaching received by Leicester clinical medical students was carried out using a student diary. This instrument enables a data base to be constructed which is useful for academic and resource allocation purposes. This information can also be used to estimate the teaching time in the different sites and the source of funding of the teaching staff and thereby provide insights into the 'knock-for-knock' system of informal cost-sharing between universities and the National Health Service.

Clinical Clerkship↗

The importance of needs assessment in planning health promoting schools initiatives: comparison of youth risk behaviours of two districts in Hong Kong.

A needs assessment is recommended to be carried out before planning resource allocation in a community as it could help to identify the needs of the people. This study illustrated the importance of needs assessment in planning health promoting school initiatives by comparing the results of youth risk behaviours surveys conducted at two districts of Hong Kong, namely Tsuen Wan and North District. The findings indicated that the two districts should prioritize their resources in respect to their urgent needs. A higher proportion of students from Tsuen Wan participated in vigorous exercise regularly in comparison to students from North District. Students from North District consumed more vegetable per week and exhibited less depressive symptoms than students from Tsuen Wan. The availability of data on youth risk behaviours of the two districts would provide information for strategic planning and direct decision-making in youth health programmes.

Adolescent↗

Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults.

BACKGROUND: Better understanding the impact of changes in physical activity behavior on short-term health care charges may inform resource allocation decisions to increase population levels of physical activity. This study examines the prospective relationship of changes in physical activity status on short-term changes in health care charges for older adults. METHODS: A prospective cohort study was done on a stratified random sample of 2,393 adults aged 50 and older enrolled in a Minnesota health plan, predicting changes in resource use between two periods (September 1994 to August 1995 and September 1996 to August 1997) based on billed health care charges. RESULTS: After adjustment for age, gender, comorbidity, smoking status, and body mass index, all physical activity states had declining health care charges, relative to those who were consistently inactive. Subjects who increased their physical activity from 0-1 to 3+ days/week had significant declines in their mean annualized total charges (-2,202 dollars, P < 0.01) relative to those who remained inactive. CONCLUSIONS: Increased physical activity among older adults is associated with lower health care charges within 2 years, relative to charges for those who were persistently inactive. These cost savings may justify investments in effective interventions to increase physical activity in older adults.

Adult↗

Occupational medicine. An overview of management.

Management is the art of utilizing all available resources to accomplish a given set of tasks in a timely and economical manner. A complete job description for a manager would include diplomacy, coercion, politics, psychology, budgeting, evaluation and a host of other attributes. Each individual manager evolves a personal style within an organizational culture. No two positions or individuals are ever exactly alike. The successful manager must be able to allocate resources and motivate subordinates to accomplish goals often imposed from external sources (i.e., upper management). The successful manager may retain previously acquired technical skills; frequently these are lost, being replaced by new knowledge. The successful manager is one who understands the local organizational milieu. The theories discussed above are only guidelines. Just as each patient is approached differently, so too are different managerial positions.

Commerce↗