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PubMedDate not supplied

Performance indicators and performance assessment in the UK National Health Service: implications for management and planning.

Throughout the Western world policy makers are seeking to control the use of health care resources. Often the primary motive for these policies is to control or the total level of public expenditure on health care. One manifestation of such policies in the USA is the use of diagnostic related groups (DRGs), and this instrument is now being adopted in Europe (for example, in France as from January 1986). In Britain, as similar management tool is that of performance indicators, which are basically measures of input and activity. In this article it is argued that management responses to these measures may not lead to greater efficiency in resource utilization. Whilst the use of input and process measures to control resource allocation are better than no controls at all, the achievement of efficiency requires that such measures are supplemented with the assessment of outcomes and analyses of input-output relationships. Such supplementation, for example by using quality-adjusted life years (QALYs), is urgently required if policy makers are not to become disenchanted with the usefulness of existing performance indicators.

Efficiency↗
PubMed1979

A comparison of two proxy measures for morbidity.

The use of standardised mortality ratios (SMRs) as a proxy measure of morbidity for resource allocation purposes in the National Health Service (NHS) has been widely criticised. The small number of deaths from infectious diseases makes it necessary to consider whether there are more appropriate measures. The standardised notification rate (SNR) was compared with the SMR for respiratory tuberculosis and it appears to be a better proxy for morbidity.

Adolescent↗
PubMed1993

The cost and efficiency of public and private health care facilities in Ogun State, Nigeria.

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating a full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.

Budgets↗
PubMedDate not supplied

Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States.

BACKGROUND: Estimates of the cost of long-term complications of a primary deep vein thrombosis (DVT), including the post-thrombotic syndrome (PTS) and recurrent venous thromboembolism (VTE), may be relevant for resource allocation decisions. OBJECTIVE: The objective of this study was to provide US cost estimates of the long-term complications of a primary DVT, which occurs in approximately 5% to 20% (with adequate thromboprophylaxis) and 50% (in the absence of thromboprophylaxis) of total hip replacement surgeries (THRS). METHODS: A literature-based model was used to project the excess long-term complication costs of DVT following THRS. The model simulated the natural history of DVT complications using published estimates of the incidence and prognosis of PTS and recurrent VTE. Each complication was assigned a cost obtained by multiplying the amount of resources used in its management by the unit price of these resources. RESULTS: The annual per-patient cost of each complication was as follows: mild-to-moderate PTS, 839 dollars in the first year and 341 dollars in subsequent years; severe PTS, 3817 dollars in the first year and 1677 dollars in subsequent years; DVT, 3798 dollars; and pulmonary embolism, 6604 dollars. The average discounted lifetime cost of DVT complications was estimated to be 3069 dollars (95% interval 2091 dollars-4279 dollars). CONCLUSIONS: The long-term complications of a primary DVT represent a significant economic burden. Preventing a DVT could arguably lead to substantial savings in long-term DVT complications.

Aged↗
PubMed2000

Federalism, entitlements, and discretionary grants: the fiscal context of national support for immunization programs.

This paper defines the appropriation and resource allocation structure of federal government programs that deliver vaccines to the public through state and local governments, with a special focus on the Centers for Disease Control and Prevention (CDC) Section 317 program. The paper places these programs in the context of the overall intergovernmental finance system of the United States, and the manner in which that system has responded to societal changes in other areas, such as unemployment insurance and environmental protection. The paper concludes that a changing environment for vaccine financing, and uncertain appropriations for state government immunization infrastructure, may have made the current CDC Section 317 program inadequate. Increased entitlement resources for federally funded vaccines have not been matched with increased and stable resources for the balance of program costs. To the contrary, funding provided to the Section 317 program has proven unstable, and its discretionary appropriations have proven vulnerable to both executive and legislative branch earmarking for such activities as overseas disease eradication or home state earmarking by congressional appropriations subcommittee members. In addition, the rigidity of some CDC program requirements makes it difficult for states to effectively use program funds. Consideration should be given to strengthening the Section 317 program and its relationships to other federal aid programs to ensure that adequate immunization protections are provided in all states to adequately protect all citizens.

Centers for Disease Control and Prevention, U.S.↗
PubMed2006

Evolution of HIV/AIDS prevention programs--United States, 1981-2006.

When the first cases of what would become known as acquired immunodeficiency syndrome (AIDS) were reported in 1981, the magnitude of the epidemic and the numbers of deaths were unimaginable. During the next 25 years, an unprecedented mobilization of individual, community, and government resources was directed at stopping the epidemic. CDC currently supports a wide range of human immunodeficiency virus (HIV) prevention activities in the United States, including 1) collection of behavioral and HIV/AIDS case surveillance data that document trends in the epidemic and risk behaviors; 2) programs conducted by state, territorial, and local health departments, community-based and national organizations, and education agencies; 3) capacity building to improve HIV-prevention programs; 4) program evaluation to monitor the delivery and outcomes of prevention services; and 5) research leading to new strategies for preventing transmission of HIV/AIDS. Since 1994, local and state health departments have allocated resources to specific programs and populations through local community planning processes that involve health department staff, prevention providers, and members of affected communities. A three-pronged approach has been developed, consisting of 1) prevention activities directed at persons at high risk for contracting HIV; 2) HIV counseling, testing, and referral services; and 3) prevention activities directed at improving the health of persons living with HIV and preventing further transmission.

Communicable Disease Control↗
PubMed1995

The use of fuzzy sets techniques in managing health organizations.

During the management process in health organizations, certain situations can arise when data necessary for decision-making is in fuzzy form. In such cases, problems may be solved using fuzzy sets techniques just the way they are used in diagnostics, laboratory investigations, and other patient care processes. Sometimes there are certain situations when a problem could be solved by traditional methods (i.e., mathematical programming); however, resolution requires great efforts in data acquisition and complicated calculations. At the same time, it cannot provide 100% accuracy because of rapid changes to what can be considered as the norm. In such cases, the use of fuzzy sets techniques may also be justified. The aim of this investigation is to prove that results obtained using fuzzy sets techniques will not be much less exact then those with the use of traditional methods. As an example, the problem of resource allocation among consulting rooms in the outpatient division of one hospital in Tbilisi was chosen. Our aim was to minimize patients' queues as well as physicians' idle time. Although similar problems have been solved by operation research specialists since 1956, as a rule, they have required intensive information acquisition about real volume loads of departments and hard calculations. Instead, one could have obtained the same information (viz., which of the departments of a health institution was "overloaded", "normally loaded," or "underloaded") relying on personnel estimates. Using such approximations and fuzzy sets techniques, one can avoid tiresome data acquisition and complicated calculations. Moreover, in solving resource redistribution problems, one can take into account not only the irregularity of patient distribution among consulting rooms, but also other factors (e.g., the availability of certain specialists, etc.). In order to compare both methods, data about real consulting times of outpatients in the hospital was acquired. A model for minimizing the total time wasted by patients in queues was constructed and the problem was solved using an integer programming method. Additionally the same consulting rooms were grouped into following categories: 1) "very underloaded"; 2)"underloaded"; 3)"normally loaded"; 4)"overloaded"; and 5)"very overloaded." The proposition about the redistribution of their opening times was formulated using fuzzy sets techniques. The comparison of results gained by both methods has shown that the use of fuzzy sets techniques is quite permissible and sometimes more reasonable for solving certain health care management problems.

Appointments and Schedules↗
PubMed2002

Degradation model: a quantitative EIA instrument, acting as a decision support system (DSS) for environmental management.

Environmental assessment of alternative development plans, programs, and policies may bring conflict among decision-makers, particularly when some quantitative measures for decision-making are needed and where cumulative impacts are neglected. Environmental impact assessment (EIA) and environmental economics theories, despite their usefulness, are not capable of addressing those issues and problems alone. In recent years, the decision support system (DSS) has provided some solutions, but mathematical analysis of the system to show the internal structure of the problem is not always possible. To addres the above shortcomings and ongoing problems of decision-making in Iran, a degradation model (DM) was introduced as an instrument of EIA, to act as a DSS for managers. The model is a compromise between knowledge-based decision support systems, detailed models, digested information models, and the basic theorem of environmental economics. In the present study (1996-2000), the model was applied in three provinces of Iran, representing three of four biogeographical regions of Iran. The study area was divided into a set of grids (100 km(2)). The degradation coefficient ( H) was computed for all grids (1333), representing the degree of degradation in the grid. It is obvious that the higher the coefficient the more area is degraded and less prone to further development, and vice versa. In order to provide decision-makers with a set of quantitative measures to observe impacted areas (critical and noncritical) for resource allocation and further development, the degradation coefficients of all grids were classified into categories and criteria, using a fuzzy set theoretic approach. Accordingly, only 24% of study areas are prone to further development. The degradation model as a knowledge-based decision support system has its strengths and weaknesses, but it has solved managers' ongoing problems in Iran and it could be used elsewhere.

Conservation of Natural Resources↗
PubMed1986

Elderly services program: VNA of the Valley community health in Derby, Connecticut.

Since the inception of the mental health program in the VNA of the Valley the concept of providing elderly mental health services has evolved into a well-rounded psychogeriatric program. The growth of services have been reflected in the programs, structures, policies, staffing and number of persons served. Additionally, requests for service from physicians and families are increasing, calling for more creative ways to use the limited resource available. The placement of this service in a home health agency has been important in providing a comprehensive program and allowing all the resources of the agency to be used appropriately. It has been a great benefit to management and staff to have psychiatric nurses in the agency who are available for consultation on those cases that require mental health evaluation or intervention. The collaboration with the local community mental health center and its other affiliates has also been extremely important in assuring that the patient moves along the continuum of care necessary to meet his needs. Too often the elderly get lost in the maze of mental health services that are provided for the younger client who can be vocationally rehabilitated. The state of Connecticut has been progressive in allocating resources to provide services to this population that is indeed at risk for hospitalization and in danger of jeopardizing their quality of life and that of their families.

Aged↗
PubMed1998

Preventive dental care of children and adolescents in the 1990s: Denmark, Iceland, Norway, and Sweden.

This article describes the provision of preventive care for children and adolescents in Denmark, Iceland, Norway, and Sweden in the 1990s. It includes information on personnel giving preventive care, administration of the dental care system, strategies and methods used for prevention, and resources allocated for preventive dental care. In all these countries comprehensive and systematic dental care, subsidized or free of charge, has been instituted for children and adolescents. However, comparisons between the countries show significant differences in the organization of the dental care for children, the time used for preventive care, the recall routines, and the implementation of risk-based and population-based preventive strategies. The relative importance of different caries-prevention methods (fluorides, hygiene, and diet) reported by the clinicians varied between Denmark, Iceland, Norway, and Sweden. While variation poses rather than answers questions concerning effectiveness, available data provide evidence of differences in the input of resources. Unless the dental profession addresses the issue of effectiveness of preventive dental care, politicians and administrators in a cost-containment context will easily conclude that least is best.

Adolescent↗
PubMedDate not supplied

Making capitated Medicare work for women: policy and research challenges.

Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

Aged↗
PubMed2005

Acute neurophysiological effects of the hypnotic zolpidem in healthy volunteers.

INTRODUCTION: The imidazopyridine zolpidem is a hypnotic drug with relative selectivity for the benzodiazepine (BZP) type 1 receptor subtypes displaying a different biochemical structure to that of BZPs. Little is known of its electrophysiological effects. PURPOSE: The aim of the present study was to investigate the acute neurophysiological effects of clinical oral doses of zolpidem. METHODS: This was a double blind, independent group design study. Thirty-six young, healthy volunteers were randomly allocated to one of three groups--zolpidem (5 mg and 10 mg) and placebo. In addition to ERPs, behavioural measures were used to examine sedative effects of the drug. RESULTS: ERPs were affected in a similar way to that described after sedative/hypnotic drug ingestion: increased N2 and P3 latencies and decreased N2 and P3 amplitudes. However, contrary to what is expected of a hypnotic drug, there was no change with N1 while P2 amplitude increased after the highest dose. CONCLUSIONS: Because zolpidem showed different effects in different components, it seems to first enhance or preserve initial orienting (no change in N1), after an increase of P2 and then drastically diminish resource allocation (affecting N2 and P3 latencies and amplitudes). The study with ERPs, therefore, allows a more direct "moment to moment" investigation of finer mechanisms of changes in cerebral processes underlying the acute ingestion of the drug in question. The effects on N2 and P3 amplitudes and latencies were similar to those of other sedative/hypnotic drugs. However, zolpidem led to an unexpected increase in P2 amplitude; this effect may be related to its selective receptor binding profile and warrants further research.

Adult↗
PubMed2002

Visual receptive field modulation in the lateral intraparietal area during attentive fixation and free gaze.

The receptive field (RF) of neurons recorded from the lateral intraparietal area (LIP) was quantified using a rapid, computer-driven mapping procedure. For each neuron, the RF was mapped: (1) during attentive fixation and (2) during free visual exploration. RF location, size and internal structure were modulated by the mapping context in over two-thirds of the recorded neurons. The major trend was a proportionally larger amount of neuronal visual resources allocated to central space during fixation, and an attenuated center-to-periphery gradient in the visual field representation during free gaze. A population approach shows that these spatial modulations are accompanied by changes in the signal-to-noise ratio of the information carried in the RF substructure. We related these neurophysiological observations to behavior, by comparing the characteristics of saccades elicited during fixation and free gaze. Together, the results suggest that the dynamics of LIP visual RFs may characterize both the state of engagement of attention and the power of resolution of visual analysis: during fixation, the neural population is locked in a filter state concentrating the processing resources at the fovea, while during free gaze, the population shifts to a detector state spreading the resources more evenly across the visual field.

Animals↗
PubMed1995

Cultivating curricular reform.

Since the 1960s there has been pressure to reform medical education in a more humanistic direction. One reason this has been difficult is that most medical schools have been forced to maintain themselves on resources allocated to support research and the technology of specialized tertiary care. Nevertheless, many people believe that medical education can still change because of changes taking place outside the sciences, such as a redefinition of the meaning of health and the need to provide better health care to the U.S. population at a lower cost. Taking this optimistic view will help strengthen reformers' resolve for curricular change and the incorporation of important areas such as family violence into medical students' education. There are numerous barriers to curricular change. Yet there are useful principles that can guide reform efforts, such as having an explicit rationale for the desired change, focusing on educational goals rather than on resources for their implementation, recruiting support from the departmental and school leadership, anticipating negative reactions, and recognizing the need for negotiation. There are also principles to foster successful implementation, the most important of which is to have everyone involved agree on the goals of the new program and participate in the process. The way to increase an emphasis on family violence issues is to find areas in the curriculum where these issues can be integrated with current teaching. Finally, a medical school curriculum on family violence does not need to be all-inclusive, but instead should prepare a good foundation so that students can expand their knowledge and skills during residency training and medical practice.

Clinical Competence↗
PubMed2005

Engendering the bureaucracy? Challenges and opportunities for mainstreaming gender in Ministries of Health under sector-wide approaches.

The increasing ascendancy of 'gender mainstreaming' as the central approach to improving gender equity has largely determined strategies to integrate a gender focus in sector-wide approaches (SWAps). This paper explores the impetus for and process of gender mainstreaming in SWAps in the Ministries of Health in Uganda, Ghana, Malawi and Mozambique, and outlines some achievements and challenges. The shifting and contested relationships between the Ministry of Health, donors and other government ministries (such as Ministries of Finance and Ministries of Women's Affairs/Gender) are important in shaping the opportunities and constraints faced in gender mainstreaming. The refocusing of resource allocation to different sectors has led to changes in the balance of power between the various actors at the national level, with diverse implications for promoting gender equity in health. Some of the achievements to date and ongoing challenges are explored through concrete examples from different countries. These include: the development of structures for mainstreaming, including the dilemmas of the 'focal points' approach and the role of national gender mainstreaming machinery; the need for training and building capacity to identify and address gender issues, which involves engaging with new languages and concepts, and developing new skills; building alliances, consensus and momentum; integrating gender concerns into policy and planning documents; and promoting gender equity in human resources in the health sector. Cross-cutting themes underlying these challenges are the need for gender-specific information and ways to finance mainstreaming strategies. Implications are drawn for ways forward, without losing sight of the challenge of translating discourses of gender mainstreaming, and its central ideal of social transformation, into pragmatic strategies in the bureaucratic environment.

Africa↗
PubMed2006

National environmental health measures for minority and low-income populations: tracking social disparities in environmental health.

Healthy People 2010 [US Department of Health and Human Services, 2004. Healthy People 2010. Available: http://www.healthypeople.gov/Publications/ [accessed May 22, 2004]] has established as a top priority the elimination of health disparities. Current research suggests that characteristics of the social, physical and built environment contribute to these disparities. In order to track progress and to assess the potential contributions of the various components of the "environment," tools specific to environmental health disparities are required. In this paper, we discuss one potential tool, a set of candidate measures that may be used to track disparities in outcomes, as well as measures that may be used analytically to assess potential causal pathways. Several other reports on health and environmental measures have been produced, including the Environmental Protection Agency's (EPA) America's Children and the Environment. However, there has not been a comprehensive discussion about environmental measures that focus on racial, ethnic and socioeconomic disparities in health. Therefore, we focus on measures specific to historically disadvantaged populations. Based on a conceptual framework that views health disparities as partially driven by differential access to resources and exposures to hazards, we group the measures into four categories: social processes, environmental contaminants/exposures, bodyburdens of environmental contaminants, and health outcomes. We provide a few examples to illustrate each category, including residential segregation, PM(2.5) exposures, blood mercury concentrations, and asthma morbidity and mortality. These measures and categories are derived from a review of environmental health disparities from several disciplines. As a next step in a long-term effort to better understand the relationship between social disadvantage, environment, and health disparities, we hope that the proposed measures and literature review serve as a foundation for future monitoring of environmental health disparities. These efforts may aid community organizations, local agencies, scientists and policy makers in allocating resources and developing interventions.

Asthma↗
PubMed2004

Effects of organizational scheme and labeling on task performance in product-centered and user-centered retail Web sites.

As companies increase the quantity of information they provide through their Web sites, it is critical that content is structured with an appropriate architecture. However, resource constraints often limit the ability of companies to apply all Web design principles completely. This study quantifies the effects of two major information architecture principles in a controlled study that isolates the incremental effects of organizational scheme and labeling on user performance and satisfaction. Sixty participants with a wide range of Internet and on-line shopping experience were recruited to complete a series of shopping tasks on a prototype retail shopping Web site. User-centered labels provided a significant benefit in performance and satisfaction over labels obtained through company-centered methods. User-centered organization did not result in improved performance except when the label quality was poor. Significant interactions suggest specific guidelines for allocating resources in Web site design. Applications of this research include the design of Web sites for any commercial application, particularly E-commerce.

Adolescent↗
PubMed2006

[Vulnerability and National Health Service].

Safegarding health has been an objective of every learned civilization, ancient and modern. In modern times, at least in the western world, the increase in longevity associated with social isolation has created further vu1nerability for the older individua1. Today, healthcare is a social burden of extremely high cost. Among us this service is provided by the National Health Service in accordance to the Constituição da República Portuguesa (Constitution of the Portuguese Republic). Despite the constitutional guarantees of equa1ity in health there are obvious discrepancies in access to health care and the conditions that promote health such as education and wealth. In a poor country, even with limited resources, inequa1ity can be minimized via policies and practical measures founded in equa1ity and social responsibility, not only the principles of economic efficiency. Only in this way can we guarantee equa1 access to health and the distribution of available resources in accordance to health care necessities. Yet, the investment in high technology among us seems out of fase with the investment in the area concerning functional recovery from high morta1ity illness, such as stroke. In Portugal the problem is extremely bad. Life expectancy has been extended but qua1ity of life is still very low. Victims of the social order, the elderly live alone without family who can care for them; on the other hand, the lack of investment in recovery and social integration of individua1s with disabling scars, Turns the ends of their life's into a nightmare for themselves and their kin. It follows stating the necessity to analyse and define the criteria to be used when allocating resources in order to guarantee equality in health and relief from suffering and also to stop discrimination of vu1nerable populations in access to healthcare. Whatever the criteria, it must be pre-defined and its principles widely discussed, reiterating, only that longevity cannot be an acceptable criteria to value life. The article concludes drawing attention to the need to invest in health education, which is just as important as the fair distribution of precious health care resources in reducing harmful risks to the most vulnerable patients.

Aged↗