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PubMed2005

Models for the organisation of hospital infection control and prevention programmes.

Hospital infection control is an essential part of infectious disease management and must be firmly structured and professionally organised. Prevention, limitation and eradication of nosocomial infections requires specific expertise not fully provided by clinical microbiologists and/or infectious disease consultants. Therefore, dedicated infection control physicians and nurses are essential. The basic components for successful hospital infection control include: (1) personnel and supporting resources proportional to size, complexity and estimated risk of the population served; (2) trained hospital infection control practitioners; and (3) the necessary structure to implement changes in medical, nursing and logistical organisation. The identification of areas of concern, provision of written policies and education still constitute the backbone of infection control. The infection control team must propose priorities and necessary resources, objectives, development methods, implementation and follow-up. The strategic approach must be discussed and approved by the infection control committee, comprising the hospital administrator(s), medical and nursing directors, a microbiologist, a hospital pharmacist and a delegation of clinicians. Follow-up of the projects is regularly presented to the committee by the infection control team. To what extent may evolution in the organisation of hospital infection control contribute to the optimisation of allocated resources and fulfillment of these objectives? From the Belgian experience, we conclude that structural changes represent an essential incentive. The impact of changes is greater when they are directed by the national authorities, providing resources and imposing new standards. Recommendations for staffing must consider not only the number of beds but also the objectives, complexity and characteristics of the patient population.

Belgium↗
PubMed1991

Cost-efficient study designs for binary response data with Gaussian covariate measurement error.

When mismeasurement of the exposure variable is anticipated, epidemiologic cohort studies may be augmented to include a validation study, where a small sample of data relating the imperfect exposure measurement method to the better method is collected. Optimal study designs (i.e., least expensive subject to specified power constraints) are developed that give the overall sample size and proportion of the overall sample size allocated to the validation study. If better exposure measurements can be collected on a sample of subjects, an optimal design can be suggested that conforms to realistic budgetary constraints. The properties of three designs--those that include an internal validation study, those where the validated subsample is derived from subjects external to the primary investigation, and those that use the better method of exposure assessment on all subjects--are compared. The proportion of overall study resources allocated to the validation substudy increases with increasing sample disease frequency, decreasing unit cost of the superior exposure measurement relative to the imperfect one, increasing unit cost of outcome ascertainment, increasing distance between two alternative values of the relative risk between which the study is designed to discriminate, and increasing magnitude of hypothesized values. This proportion also depends in a nonlinear fashion on the severity of measurement error, and when the validation study is internal, measurement error reaches a point after which the optimal design is the smaller, fully validated one.

Cohort Studies↗
PubMed1987

Applications of cost-benefit analysis to health care. Departures from welfare economic theory.

In applying the principles of cost-benefit analysis to real world problems of resource allocation particular care must be taken to ensure that the welfare economic theory which underlies the cost-benefit technique is adhered to. Major problems arise where costs and benefits are used interchangeably to represent the good and bad attributes of a programme. Furthermore, in the presence of mutually exclusive projects, focussing attention upon the net benefits (or cost-benefit ratios) of individual projects as opposed to the net benefits of the use of budgeted resources can lead to biased estimates of the shadow price of projects and, consequently, errors in analysts' conclusions. As a result, economic appraisals of individual projects are not directly relevant for choosing between mutually exclusive projects of different sizes. Both types of problem are illustrated by reference to both simple examples and published economic appraisals of health care techniques. Integer programming is proposed and demonstrated as a method of selecting between mutually exclusive projects.

Budgets↗
PubMed2001

The mode of short-term memory encoding as indicated by event-related potentials in a memory scanning task with distractions.

OBJECTIVE: Auditory event-related potentials (ERPs) were recorded during the performance of a memory scanning task, with and without distracters between the memorized items and the probe. The effect of distracters with different phonological/semantic characteristics was tested, to indicate the encoding mode in short-term memory. METHODS: Three types of sets ('memorized sets') were presented to the subject before the probe: 4 memorized digits, two memorized digits with two distracter digits and two memorized digits with two noise distracters. Potentials in response to the set items were averaged separately according to stimulus type and position in the set. Potentials in response to the probe were averaged according to the preceding stimulus sequence: 4 memorized digits, two distracter digits or two noise distracters. RESULTS: The early components (N1, P2) differed between distracter items and memorized items, indicating lower attention allocation to distracter items. In contrast, the late components (N2, P3) indicated similar processing of distracters and memorized items. Behavioral measures indicated shorter scanning times of sets with distracters. The early ERP components in response to the probe (P2, N2) indicated differences among probes according to the preceding combinations of memorized items and distracters. The late component (P3) indicated different speeds (latencies) of scanning and comparison for series with compared to without distracters, but similar processing resource allocation (amplitudes). Processing was prolonged when the distracter items were phonological. CONCLUSIONS: This study shows that distracters affect both the memorization process and the scanning and comparison in short-term memory. The stronger distraction by stimuli that are phonologically similar to the memorized items supports phonological processing in short-term memory.

Adolescent↗
PubMed1996

Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units.

OBJECTIVE: Assess the workload caused by elective routine removals of internal fracture fixation devices in a large university orthopedic and trauma unit when no premeditated departmental removal policy existed. MATERIALS AND METHODS: Data on all operations performed during a 7-year period were retrieved. Routine removals of internal fracture fixation implants were analyzed for demographic data and clinical details. Patients requiring additional procedures to manage the fracture besides simple hardware removal were excluded. Nationwide data were included for comparison. RESULTS: A total of 5,095 routine implant removal operations were performed after uneventful fracture union. The mean age of the patients was 42 years. The five most common fracture types were fractures of the ankle, the proximal femur, the tibial shaft, the femoral shaft, and the thoracolumbar spine. In 63% of the procedures, a medium-size or large implant was removed. The mean operation time was 37 minutes. The removals accounted for 29% of all elective operations and for 15% of all operations at the department. The corresponding nationwide figure was 6.3% of all orthopedic operations, the number of implant removals in the whole country being 90 operations per 100,000 person-years. CONCLUSIONS: Without a strict departmental removal policy, a remarkable portion of the resources allocated for elective orthopedic operations was spent on routine hardware removal procedures. A more rational and selective attitude toward implant removals is desirable. Further research on the disadvantages of retained hardware and the complications of implant removals is required.

Adult↗
PubMedDate not supplied

Trauma helicopter emergency medical services transport: annotated review of selected outcomes-related literature.

Based on its roots in military air evacuation, helicopter emergency medical services (HEMS) has always been emphasized as a tool for trauma transportation. Despite much discussion regarding resource allocation for HEMS, a literature search found little recent systematic review of pertinent studies. As HEMS utilization is subject to increased scrutiny in a health care dollar-conscious environment, it was felt that a compendium of available outcomes-related literature could assist those assessing utility of HEMS trauma transport. The current study utilized a Medline search to identify outcomes studies relative to HEMS trauma transport. The goal of this review is to provide a useful resource for those interested in pursuing systematic review of the HEMS trauma outcomes literature. The primary purpose of the review is bibliographic, but there is editorial comment after each paper's summary. The initial article in this two-part series focused on HEMS outcomes literature covering noninjured patients as well as papers assessing outcome in mixed trauma-nontrauma HEMS study groups.

Air Ambulances↗
PubMed2005

Modeling and analysis of protein design under resource constraints.

The potency, or fitness, of a protein-based drug can be enhanced by changing the sequence of its underlying protein. We present a novel stochastic model for the sequence-fitness relation, and estimate its four parameters from industrial data. Using this model, we formulate and analyze two variants of the protein design problem. In the single-period design problem, the designer needs to decide under capacity constraints which set of sequences to screen in order to maximize the expected fitness of the best sequence in the set. In the more general two-period design problem, the designer can afford two screening rounds and needs to allocate resources optimally across the two periods to maximize the same objective function. Analytical and simulation results allow us to assess the utility of the proposed design strategies for various parameter regimes.

Animals↗
PubMedDate not supplied

District health systems in a neoliberal world: a review of five key policy areas.

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.

Community Health Planning↗
PubMed1983

Health care policy: lessons from the past and issues of the future.

Liberal distributional values, the increasingly powerful capacity of medicine to provide more and better care, and concern about the health hazards of an industrial society fueled the vast expansion of the health care sector during the last 20 years. That growth was facilitated by a growing economy. The current health policy debate at one level reexamines the distributional bases of entitlement programs, and at another seeks alternative resource allocation mechanisms to reduce the cost of health care. This article has two themes. First, distributional and allocational policies are shown to be intrinsically related, so that the health policy debate is fundamentally a clash between liberal and libertarian values. Second, the inexorable social forces driving the health care system are shown to be the aging of the population and the rapid expansion of technology. The resulting dynamics imply the further growth of the health sector, now in the environment of a sluggish economy. Future policies will have to struggle with how to ration scarce health resources and how to reorient the health care sector to the problems of the aged.

Health Policy↗
PubMed1998

Antimicrobial resistance in the intensive care unit: impact of new patterns.

The effects of resistance are being observed on an increasing scale in the intensive care unit (ICU). Multi-resistant organisms are diminishing our ability to treat and control the spread of infection. Strategies for the control of resistant organisms in the ICU must be based on the underlying pathophysiology of resistance mechanisms. Resistance is also influenced by the setting in which health care is provided. In the United States (US), changes in the health care delivery system have had a dramatic impact on the number and type of ICU patients. Project ICARE (Intensive Care Antimicrobial Resistance Epidemiology) is a co-operative project to measure antibiotic resistance and antibiotic use. Results show a relative increase in the number of ICU beds in US hospitals. They also indicate a significant stepwise decrease in the percentage of resistant organisms isolated from ICU patients, non-ICU inpatients, and outpatients. These results suggest that resources allocated to control of antimicrobial resistance should continue to be focused on the hospital and particularly the ICU. Study findings also indicate that antimicrobial use and resistance are usually, but not always, linked. This means that strategies for dealing with resistance must address several additional factors including infection control practices, community burden of resistance, and possibly others. Thus national or regional guidelines for preventing resistance will have to be modified to take into account local care patterns, problems and resources. When dealing with resistance in the ICU, 'one size will not fit all'.

Delivery of Health Care↗
PubMed2002

Comparative analysis of QTLs affecting domestication traits between two domesticated x wild pearl millet ( Pennisetum glaucum L., Poaceae) crosses.

Comparative mapping of Quantitative trait loci (QTLs) involved in domestication of adaptative syndrome traits of pearl millet was realized at the intra-specific level using two F(2) populations derived from domesticated ( Pennisetum glaucum ssp. glaucum) x wild ( Pennisetum glaucum ssp. monodii) crosses. The two domesticated parents analyzed differ in their geographical origins, agronomic characteristics and life cycles. In both populations, two regions of the genome were identified on linkage groups 6 and 7, that controlled most of the key morphological differences. The importance of these two linkage groups reveals their central role both in the developmental control of spikelet structure and in the domestication process of this crop. In contrast, QTLs involved in traits that are components of yield and measure differences in resource allocation (such as the shape of the spike, the number of spikes per plant and plant height) show a low level of correspondence among our two crosses. The results of the comparative mapping between cereals, although preliminary, reveal that genes involved in seed-shattering could correspond in maize, rice and sorghum. The evolutionary significance of our results, and especially the relationships between genome organization and cereal domestication, are discussed. The potential use of these results in pearl millet genetic-resources enhancement are presented.

Journal Article↗
PubMed2005

Aspects on priority settings in cancer treatment and care.

The widening gap between available resources and increasing possibilities to diagnose and treat different medical conditions has resulted in new attention to priority setting. The issue is complicated and harbours several obstacles because of different valuations concerning the needs of patient groups, the true results (patient benefit) of medical actions, and also important ethical considerations. Earlier attempts have been unsuccessful in introducing a prioritization milieu into the medical profession, probably due to vague requests for an open and sharp prioritization process. With a sharpened competition of allocating resources for different medical actions, the medical profession of the cancer sector needs to have a tool for explaining consequences for the different cancer patient groups and what is achieved by the cancer treatments and the care. A model for ranking lists consisting of pairs of patient conditions and medical actions is presented, and the principle for using these lists for priority setting in medical society is discussed.

Decision Making↗
PubMed2002

Physicians' preferences and expectations in stroke rehabilitation--results of a case-based questionnaire survey.

PURPOSE: Analysis of medical decisions in the differential allocation of stroke rehabilitation programmes. METHOD: Medical specialists routinely involved in the treatment and rehabilitation of stroke patients from acute hospitals, rehabilitation centres, and the Medical Services of the Workers' Pension Funds of Sachsen-Anhalt and Mecklenburg-Vorpommern were included in a systematic survey, in which they had to give their opinions on the individually optimal rehabilitation setting and therapies and probable outcome on the basis of case vignettes. These specialists are crucial for decision-making in rehabilitation resource allocation. RESULTS: Both allocation and prognosis did not depend only on patient but also on physician characteristics. Neurologists tended to prefer outpatient rehabilitation and expected a greater effect of rehabilitation upon ADL-function than specialists from other professions. Preferred rehabilitation setting did not influence the physicians' subjective prognosis. For patients who qualified both for in- and outpatient rehabilitation, the two settings, therapeutic potentials were considered to be equivalent. CONCLUSIONS: Differences in setting and treatment preferences between experts concerning optimal treatment cannot be resolved on the basis of available evidence. Further data are required that allow to decide which type of rehabilitation is best suited for a given patient.

Adult↗
PubMed1994

Adapting DRGs: the British, Canadian and Australian experiences.

The DRG classification was developed in the United States, and has been widely used there for analytical and resource allocation purposes. Its utility has been recognised in other countries. Some have adopted US versions without change, and others have chosen to develop their own adaptations. This paper discusses the processes and outcomes of adaptation in Canada, Britain and Australia. An attempt is made to generalise the trends. It is concluded that there is a high degree of similarity of intent, although different solutions have been adopted in some cases. Where major differences remain, they are mostly a consequence of the lack of resources to pursue all opportunities for refinement at the same time. All three countries have correctly focused on involvement of their own clinician groups. However, they have tended to restrict their view to US experiences when looking overseas. It is argued that greater attention should be paid to sharing their ideas with countries with which they have a greater degree of similarity.

Australia↗
PubMed1997

Ethical conflicts in home care. Patient autonomy and physician advocacy.

OBJECTIVE: To identify whether and how family physicians practising home care resolve ethical dilemmas in clinical management of homebound patients and to examine whether the self-reported, theoretical ethical positions of these physicians match their actual patient management. DESIGN: Cross-sectional survey. SETTING: Quebec community-based home care program. PARTICIPANTS: Quebec family physicians actively involved in community-based home care: 85 men and 65 women. MAIN OUTCOME MEASURES: Physician level of agreement with theoretical ethical statements about autonomy, caregiver needs, and resource allocation; management options chosen for a clinical case vignette; and mechanisms used for resolving conflicts. RESULTS: There were 209 respondents to the 279 questionnaires sent (75%). Of these, 59 who were not currently involved in home care were excluded, leaving 150 participants. Most (83.3%) physicians surveyed agreed with the ethical principle of patient autonomy; 88.7% agreed that the interests of family caregivers are important in decisions regarding patients, and 72.0% agreed that limiting home care services is reasonable in the context of limited resources. In managing a patient, 65.3% of physicians thought the patient should be placed in a nursing home against her wishes because of "danger to self," while 82.7% felt she should be placed if the caregiver is "exhausted." Three quarters of physicians did not limit or decrease home care services, despite noncompliance. CONCLUSIONS: Family physicians practising community-based home care in Quebec have practical views on various ethical principles guiding home care practice. Except in the area of limiting or discontinuing home care services, their ethical framework is reflected in a case vignette of patient management.

Adult↗
PubMed2003

Physicians' preferences and expectations in traumatic brain injury rehabilitation--results of a case-based questionnaire survey.

PURPOSE: Analysis of medical decisions in the differential allocation of traumatic brain injury (TBI) rehabilitation programmes. METHOD: Medical specialists routinely involved in the treatment and rehabilitation of TBI patients from acute hospitals, rehabilitation centres, and the Medical Services of the Workers' Pension Insurance of Sachsen-Anhalt and Mecklenburg-Vorpommern were included in a systematic survey, in which they had to give their opinions on the individually optimal rehabilitation setting and therapies and probable outcome on the basis of case vignettes. These specialists are crucial for decision-making in rehabilitation resource allocation. RESULTS: Both allocation and prognosis depended mainly on patient characteristics. In a mixed logistic regression model, which takes into account that: (a) patient and physician characteristics may influence each other; and (b) that expert assessments might be correlated, setting preferences were related to chronicity and degree of motor and cognitive impairment, but also to the institutional background of the reviewer. Neuropsychological therapy dominated intervention recommendations, followed by physio- and occupational therapy. A comparatively great demand of psychotherapy and medicosocial assessment was recognized. Preferred rehabilitation setting did not influence the physicians' subjective prognosis. Older, chronic and motorically impaired patients were considered to profit less from rehabilitation. Physician characteristics and recommendations of either rehabilitation setting or therapies did not influence prognostic expectations. CONCLUSIONS: Physician characteristics influenced setting preferences. Preferences for type of treatment and ADL-prognosis depended on patients' variables only. Expected effects of rehabilitation were independent on rehabilitation setting and kinds of treatment.

Activities of Daily Living↗
PubMed1988

Principles for a national health program: a framework for analysis and development.

Growing gaps in health insurance coverage have generated increased interest in enactment of major reforms. A framework for evaluating proposals embodying different approaches to a national health program is offered, highlighting seven dimensions: inclusiveness of coverage; comprehensiveness of benefits; financing methods; efficiency of resource utilization; extent of planning and market forces in resource allocation; accountability to beneficiaries; and political feasibility. Four health care reform bills in the Congress are shown either to emphasize political feasibility at the expense or universal coverage and comprehensive benefits, or to stress coverage, benefits, and system reform at the cost of such feasibility.

Financing, Organized↗
PubMed2000

Payer status and the utilization of hospital resources in acute myocardial infarction: a report from the National Registry of Myocardial Infarction 2.

BACKGROUND: Prior studies have suggested that payer status may be an important determinant of medical resource utilization and outcome in acute myocardial infarction (AMI). METHODS: A national cohort of 332,221 patients with AMI enrolled from June 1994 to July 1996 were compared within 5 payer groups to ascertain the influence of payer status on hospital resource allocation for AMI in the United States. RESULTS: Medicare comprised the largest proportion (56%), followed by commercial insurance (25%), health maintenance organization (HMO) (10%), uninsured (6%), and Medicaid (3%). Compared with commercially insured patients, Medicare and Medicaid patients received fewer reperfusion therapies, underwent fewer invasive cardiac procedures, and had longer hospitalizations. After adjusting for differences in clinical characteristics, Medicare recipients were as likely as commercially insured patients to receive acute reperfusion therapies or any invasive cardiac procedure. Uninsured and HMO patients tended to utilize hospital resources with intermediate frequency. Medicare recipients aged 65 years or older and the HMO group had similar hospital mortality rates compared with the commercial group (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.96-1.20 and OR, 0.93; 95% CI, 0.83-1.04, respectively), but Medicaid and uninsured groups had higher hospital mortality rates compared with the commercial group (OR, 1.30; 95% CI, 1.14-1.48 and OR, 1.29; 95% CI, 1.12-1.48, respectively). CONCLUSION: This report suggests significant variation by payer status in the management of AMI throughout the United States, but no important differences in mortality among the 3 largest payer groups.

Aged↗