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PubMed1991

The cost-effectiveness of treating mild-to-moderate hypertension: a reappraisal.

The cost-effectiveness of treating mild-to-moderate hypertension (diastolic blood pressures, 90-114 mmHg) was evaluated using the latest available information on both costs and benefits. The net health care costs of lifelong treatment for hypertension, at a 5% discount rate, ranged from 1491 pounds to 2752 pounds in men and from 1568 pounds to 2850 pounds in women in New Zealand in 1988 (1.00 pounds = $NZ 2.81). These figures take into account the savings in health care costs arising from stroke prevention. The net health care benefits, measured in quality-adjusted life years (QALYs) discounted at 5%, ranged from--2 days (a net negative effect of treatment) to 64 days in men and from--18 days to 35 days in women. The cost-effectiveness of antihypertensive therapy discounted at 5% (excluding categories of patients for whom the ratio was undefined due to a net negative effect of treatment on QALYs) ranged from 11,058 pounds to 63,760 pounds per QALY gained in men and from 22,060 pounds to 194,989 pounds per QALY gained in women. Treatment was more cost-effective in men than in women, in older age groups and at higher levels of pretreatment diastolic blood pressure. The cost-effectiveness ratios were highly sensitive to the discount rate used (with the majority of ratios in women being undefined at a 10% discount rate) and the costs of the regimen used (diuretic monotherapy being the most cost-effective, followed by beta-blockers, then angiotensin-converting enzyme inhibitors), as well as to the assumptions made about the impact of medication side effects on patient quality of life. These results call for a re-examination of resource allocation to antihypertensive treatment and point to the need to make assessments of the cost-effectiveness of alternative, non-pharmacological approaches to stroke prevention.

Antihypertensive Agents↗

PubMed1993

Cost-effective nursing practice: cost-awareness and empowerment.

Cost-effective nursing practice is essential to succeed today as resources allocated to health care are declining. Realizing that any change poses a threat to our security, it is imperative that stakeholders be permitted to participate in decision-making processes affecting their work. An honest, open exchange of ideas towards cost-effective practices should be encouraged. Cost-effective behaviours are influenced significantly by negative attitudes with regard to loss of human resources, increased workload, and potential pay cuts. This article describes innovative strategies which could promote successful cost-effective nursing practice, including working smarter, not working harder. Topics addressed are attitude, awareness and empowerment.

Cost-Benefit Analysis↗

PubMedDate not supplied

Assessing the local need for family and child care services: a small area utilization analysis.

This article reports the findings of a study to develop a new method for allocating resources to family and child care services within Northern Ireland. Downloads from financial and client databases, together with a survey of social worker case activity, were used to estimate utilization costs across 500 local areas. Regression techniques were then used to account for variations in these costs in terms of local socioeconomic conditions. The resultant needs index represents a fair and equitable means of allocating central family and child care budgets to local units of management and service delivery.

Adult↗

PubMed1997

[Assessment of need for nursing care].

The ideal prerequisites for the evaluation of care needs in geriatric patients are mainly four: First a comprehensive assessment of the status of the geriatric patient. Second the existence of procedural standards. Third the existence of consensus about what quality standards in geriatric medicine could be and fourth a resource allocation system that gives some confidence in its capacity to set clinically sound incentives and its intention to guarantee quality and equity. Because of the fact, that the author is convinced that the US (Omnibus Budget Reconciliation Act (OBRA-87) mandated Minimum Data Set (MDS) for nursing homes with the connected Resident Assessment Instrument (RAI) meets some of these criterias, this system and the Resource Utilisation Groups (RUGs) case-mix methodology which is based on MDS data is described.

Aged↗

PubMed2005

Building capacity for risk factor surveillance in developing countries: a new approach.

The need to create surveillance systems that go beyond data release and generate useful, relevant and accessible information has been widely recognized. To reach this goal the design and implementation of surveillance systems should consider not only technical issues but aspects that guarantee their sustainability and utility and more important, the utilization of surveillance data for resource allocation and planning of health programs and interventions. Until now key issues have been neglected, such as political will, community involvement, decision-making processes and accountability in surveillance outcomes. For many years we have faced the same problems, all within an epidemiological mosaic where infectious and communicable diseases coexist, with limited capacity to conduct surveillance, low priority given by decision-makers, lack of resources, scarce utilization of information, competing priority between chronic, infectious diseases and risk factors surveillance. Technical, management and political approaches involving new partnerships, new ways to involve different stakeholders in the process, new methods and tools, ways to overcome resource restrictions and improve surveillance effectiveness, have to be achieved. An alternative approach has been suggested to meet the above problems and to make surveillance socially responsible; relevant and effective, not only for reporting, but for its contribution to produce the needed health changes and sustain these outcomes. The vision, strategies, methods, tools and results of a community-based surveillance system are presented. Three aspects are addressed, the context in which the surveillance is applied; the theory supporting behavioural risk factor surveillance; the perspectives, goals, solutions and lessons learned from previous experience.

Child↗

PubMed1998

Geography and mental health: a review.

In our current health care context, characterized by fiscal restraint and decentralization of accountability for health to regional authorities, geographic inequities in need, access to care, utilization, and health outcomes will come under increasing scrutiny. Knowledge gained from ecological studies about geographic disparities in mental health are likely to have important implications for policy, program planning, and resource allocations. In light of the growing relevance of the geography of mental health, this paper will review (1) selected contributions of geographic studies to the field of mental health, (2) common ecologic study approaches used in most geographic studies, (3) key conceptual and methodological challenges related to the application and interpretation of ecologic models in mental health, and (4) the wider potential of this technique for resource equity. Given the importance of geography for needs assessment and service planning, it is surprising that geographic study designs, which use ecological data, have not received greater attention as an important and viable method of assessing population mental health.

Diagnosis-Related Groups↗

PubMed1995

The British Columbia Continuing Care system: service delivery and resource planning.

The Ministry of Health and Ministry Responsible for Seniors in British Columbia, Canada, has developed a comprehensive and integrated service delivery system for the care of the elderly and the disabled. This system has a single point of entry, and contains all of the major components of Long-Term Care and Home Care services under one administrative umbrella, the Continuing Care Division. This paper presents on overview of the Division's service delivery system and its planning framework. The latter provides a vehicle for decision makers to pro-actively re-allocate resources from residential services to community and home-based services within Continuing Care.

Aged↗

PubMed1999

Relationship between modifiable health risks and short-term health care charges.

CONTEXT: If physical inactivity, obesity, and smoking status prove to contribute significantly to increased health care charges within a short period of time, health plans and payers may wish to invest in strategies to modify these risk factors. However, few data are available to guide such resource allocation decisions. OBJECTIVE: To examine the relationship of modifiable health risks to subsequent health care charges after controlling for age, race, sex, and chronic conditions. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of a stratified random sample of 5689 adults (75.5% of total sample of 7535) aged 40 years or older who were enrolled in a Minnesota health plan and completed a 60-item questionnaire. MAIN OUTCOME MEASURE: Resource use as measured by billed health care charges from July 1, 1995, to December 31, 1996, compared by health risk (physical activity, body mass index [BMI], and smoking status). RESULTS: The mean annual per patient charge in the total study population was $3570 (median, $600), and 15% of patients had no charges during the study period. After adjustment-for age, race, sex, and chronic disease status, physical activity (4.7% lower health care charges per active day per week), BMI (1.9% higher charges per BMI unit), current smoking status (18% higher charges), and history of tobacco use (25.8% higher charges) were prospectively related to health care charges over 18 months. Never-smokers with a BMI of 25 kg/m2 and who participated in physical activity 3 days per week had mean annual health care charges that were approximately 49% lower than physically inactive smokers with a BMI of 27.5 kg/m2. CONCLUSIONS: Our data suggest that adverse health risks translate into significantly higher health care charges within 18 months. Health plans or payers seeking to minimize health care charges may wish to consider strategic investments in interventions that effectively modify adverse health risks.

Adult↗

PubMed2000

Hospital response to DRG refinements: the impact of multiple reimbursement incentives on inpatient length of stay.

Recent research has warned that the introduction of Diagnosis Related Groups (DRGs) based on hospital treatment decisions will lead to an increase in the rate of marginal procedures and to a resumption of high medical expenditure growth rates. This paper explores the often contradictory effects of the multiple reimbursement incentives created by refinements to the Prospective Payment System (PPS) (principally, the introduction of procedure-based DRGs) on hospital resource allocation. Three effects are examined in the paper: (i) the change in primary or payment-related procedures owing to marginal reimbursement incentives; (ii) the change in secondary or non-payment-related services owing to average price incentives; and (iii) the change in average severity of both medical and surgical admissions. The model suggests that the anticipated positive effect of marginal reimbursement incentives on overall hospital resource use may be offset by several factors, most notably the lower average payment incentives of non-procedural DRGs.

Diagnosis-Related Groups↗

PubMed2003

The effects of age and domain knowledge on text processing.

The author investigated age differences in the effects of knowledge during encoding by comparing time allocated to naturalistic domain-related (cooking) and general texts among young and older adults with varying levels of (cooking) knowledge. High-knowledge individuals increased time allocated to conceptual integration when reading domain-related texts but not general texts and showed relatively greater recall for domain-related texts. These findings suggest that knowledge application can be effortful during encoding and that this effort pays off in terms of a more elaborated and integrated text representation that engenders better memory performance. There were no age differences in effects of knowledge on either resource allocation at encoding or on memory performance. These results suggest that knowledge-based processing is preserved in later life.

Adult↗

PubMed2000

Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use.

BACKGROUND: The Veterans Affairs (VA) health system has been criticized for being inefficient based on comparisons of VA care with non-VA care. Whether such comparisons are biased by differences between the VA patient population and the non-VA patient population is not known. Our objective is to determine if VA patients are different from non-VA patients in terms of health status and medical resource use. METHOD: We analyzed 128,099 records from the National Health Interview Survey for the years 1993 and 1994. We compared the VA patient population with the general patient population for self report on health status, number of medical conditions, number of outpatient physician visits, number of hospital admissions, and number of hospital days each year. RESULTS: The VA patient population had poorer health status (odds ratio [OR], 14.7; 95% confidence interval [CI], 10.7-20.2), more medical conditions (OR, 14; 95% CI, 10.5-18.7), and higher medical resource use compared with the general patient population (OR, 3.7 for 3 or more physician visits per year; OR 5.4 for 3 or more hospital admissions per year; OR, 7.7 for 21 or more days spent in a hospital per year). However, after controlling for health and sociodemographic differences, VA patients had similar resource use compared with the general patient population. CONCLUSION: Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population. Therefore, comparisons of VA care with non-VA care need to take these differences into account. Furthermore, health care planning and resource allocation within the VA should not be based on data extrapolated from non-VA patient populations. Arch Intern Med. 2000;160:3252-3257.

Adult↗

PubMed2004

Aerobic capacity is associated with 100-day outcome after hepatic transplantation.

The shortage of donor organs highlights the need to better identify patients most likely to benefit from hepatic transplantation. Reduced aerobic capacity (decreased peak oxygen consumption [VO(2)] during symptom-limited cardiopulmonary exercise testing) is frequently present in cirrhosis. Peak VO(2) during cardiopulmonary exercise testing may predict short-term outcome after hepatic transplantation. Symptom-limited testing was performed on a cycle ergometer (continuous ramp protocol) and VO(2) determined using a metabolic cart. One hundred fifty-six patients were tested; 59 subsequently underwent hepatic transplantation. Results showed that survivors and nonsurvivors were similar in age, duration of liver disease, Child-Pugh score, MELD score, resting cardiovascular function, pulmonary function, and gas exchange. The 6 (10.2%) patients dying within 100 days of transplantation were more likely to have reduced aerobic capacity (peak VO(2) <60% predicted and VO(2) at anaerobic threshold [VO(2)-AT] <50% predicted peak VO(2)) compared to survivors (4/6 vs. 7/53, P <.01). Using a multiple logistic regression model controlling for duration and severity of liver disease and time to transplantation, reduced aerobic capacity was independently associated with 100-day mortality. In conclusion, reduced aerobic capacity during cardiopulmonary exercise testing is associated with decreased short-term survival after hepatic transplantation. Further study is needed to determine if cardiopulmonary exercise testing can be used to improve allocation of donor organs. To ensure optimum allocation of donor organs, it is important to identify patients most likely to benefit from transplantation. Investigators have identified a number of preoperative, intraoperative, and postoperative factors that predict increased risk for postoperative mortality. Unfortunately, predictive accuracy has not been high, and the timing of factor identification does not optimize organ utilization. Identification of predictors of survival at the time of listing for transplantation might lead to better resource allocation.

Adult↗

PubMed1993

The public/private mix and human resources for health.

This paper examines the general question of the public/private mix in health care, with special emphasis on its implications for human resources. After a brief conceptual exercise to clarify these terms, we place the problem of human resources in the context of the growing complexity of health systems. We next move to an analysis of potential policy alternatives. Unfortunately, a lot of the public/private debate has looked only at the pragmatic aspects of such alternatives. Each of them, however, reflects a specific set of values--an ideology--that must be made explicit. For this reason, we outline the value assumptions of the four major principles to allocate resources for health care: purchasing power, poverty, socially perceived priority, and citizenship. Finally, the last section discusses some of the policy options that health care systems face today, with respect to the combinations of public and private financing and delivery of services. The conclusion is that we need to move away from false dichotomies and dilemmas as we search for creative ways of combining the best of the state and the market in order to replace polarized with pluralistic systems. The paper is based on a fundamental premise: The way we deal with the question of the public/private mix will largely determine the shape of health care in the next century.

Delivery of Health Care↗

PubMed1996

Predicting resource use for patients with traumatic brain injury.

Approximately 2 million traumatic brain injuries (TBIs) occur each year in the United States. Outcomes of TBI include catastrophic disability that affects mobility, self-sufficiency, cognition, language and communication, sensory and perceptual function, neurobehavior, marital relationships, and vocational status. Few programs exist that address all of these needs comprehensively, and resource allocation for care across the continuum for patients after TBI remains limited. In this article, the author describes outcomes of TBI, barriers to outcome achievement, and alternative care delivery approaches to achieve these outcomes.

Brain Injuries↗

PubMed1998

Shift in investment between sexually selected traits: tarnishing of the silver spoon

Studies of resource allocation strategies have concentrated on the influence of natural selection on the evolution of life history traits. To a lesser degree, the effects of trade-offs between natural and sexual selection on the evolution of allocation strategies have also been considered. Trade-offs between sexually selected traits that are important to females but that appear to differ in cost, however, have not been considered. Female green swordtails, Xiphophorus helleri, prefer males with longer swords to males with shorter swords, and in this study they demonstrated a preference for larger males to smaller males. Furthermore, sexually mature males invested differentially in body and sword growth depending on resource availability; males that had an unlimited amount of food invested in both body and sword growth, but males shifted to a food-restricted regime halted investment in body growth and invested only in sword growth. These results suggest that males shift their pattern of investment in two sexually selected traits when food becomes restricted. In general, variable environmental conditions may favour such conditional investment strategies in species in which there is more than one preferred male trait and the costs of the traits differ. Copyright 1998 The Association for the Study of Animal Behaviour Copyright 1998 The Association for the Study of Animal Behaviour.

Journal Article↗

PubMed2001

Current management of acute ischemic stroke. Part 1: Thrombolytics and the 3-hour window.

OBJECTIVE: To help family physicians who care for patients with acute stroke or who are involved in planning service delivery or resource allocation to understand recent developments in acute stroke care. QUALITY OF EVIDENCE: A MEDLINE search indicated that most data were derived from well designed, randomized, double-blind, placebo-controlled trials, including all the largest international studies and large systematic reviews. MAIN MESSAGE: Treatment of acute stroke with tissue plasminogen activator seems beneficial for certain patients with certain kinds of stroke. Because thrombolytic therapy is not without risk and requires substantial resources, it should be administered only by physicians trained in its use and in centres with the necessary experience and resources. Because time is important, an organized and efficient system of stroke care with collaboration between hospital and prehospital care providers and help from ordinary citizens is essential. CONCLUSION: Management of acute stroke is an emerging discipline; many potential therapies are still experimental.

Adult↗

PubMed1989

"How might a low-cost hospital system look?" Lessons from the Rochester experience.

An innovative, collaborative approach to promoting the effective and efficient delivery of hospital services and to maintaining the solvency of the nine participating hospitals in the greater Rochester, New York area has been successful. An evaluation of the early years (1980-1984) of the Hospital Experimental Payments Program (HEP) shows: 1) per capita hospital costs in Rochester increased at half the rate of increase of the national average; 2) by 1984, per capita hospital expenditures were at $446 compared with $521 nationally; 3) cost containment was achieved through a wide array of strategies such as changes in hospital resource allocation and physician practice patterns; and 4) during the same period, quality and access remained stable or improved. This project demonstrates that through self-control, hospitals can become efficient providers of health care.

Cost Control↗

PubMedDate not supplied

Economic and resource utilization analysis of outpatient management of fever and neutropenia in low-risk pediatric patients with cancer.

PURPOSE: To measure resource allocation in outpatient management of fever and neutropenia in low-risk pediatric patients with cancer and its impact on their families. PATIENTS AND METHODS: A prospective clinical trial was conducted. Eligible patients received a single dose of intravenous (IV) antibiotics and were observed for several hours in clinic. Patients were randomly assigned to continue either IV or oral antibiotics and were seen daily as outpatients. Charges were calculated based on the number of resources used and Medicare/Medicaid reimbursement schedules. A questionnaire was used to measure the impact of outpatient treatment on the family. RESULTS: Seventy-three episodes of fever and neutropenia were studied. The median duration of treatment was 4 days. Eighty-six percent of the episodes were managed without hospitalization. The median calculated charge was $1840. The median calculated charge for patients receiving oral antibiotics was $1544 and was significantly less than the $2039 median charge for outpatients treated with IV antibiotics. The estimated charge for comparable inpatient treatment was $4503. Nearly all families preferred outpatient care, and few reported a loss of work hours or increased child care expenses. CONCLUSIONS: Outpatient treatment of low-risk episodes of fever and neutropenia is substantially less costly than inpatient care and is preferred by most families.

Administration, Oral↗