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PubMed2000

Underestimating the value of women: assessing the indirect costs of women with systemic lupus erythematosus. Tri-Nation Study Group.

OBJECTIVE: Indirect costs result from diminished productivity and are incorporated in cost-benefit analysis to guide health resource allocation. Valuing the productivity impairment of those not involved in labor market activities is controversial but important for diseases affecting predominantly women if allocation decisions are to be economically efficient and equitable. We compared indirect costs incurred by women with systemic lupus erythematosus (SLE), a prototypical women's disease, calculated under varying assumptions for the value of diminished labor market and non-labor market activity. METHODS: Six hundred forty-eight female patients with SLE reported on employment status and time lost by themselves and their caregivers from labor market and non-labor market activities over a 6 month period. RESULTS: Average annual indirect costs ranged from $1,424 to $22,604 (1997 Canadian dollars) dependent on the value assigned to labor market and non-labor market activity. CONCLUSION: Indirect cost estimates that fail to consider longterm labor market absenteeism and diminished non-labor market productivity and do not use gender neutral wages to value labor market activity may lead to decisions that jeopardize resources for women's diseases.

Absenteeism↗
PubMed1991

Case payment: a New South Wales perspective.

This paper addresses the role of casemix systems within the NSW public health system. In NSW, Areas and Regions are funded according to a casemix modified population-based funding formula (Resource Allocation Formula). The RAF is compared with case payment as a means of funding hospitals. It is argued that because of the current shortcomings in casemix funding, including output orientation, inapplicability to ambulatory and non-acute inpatients, and limited scope for global expenditure control, case payment should not be introduced as the mechanism for funding hospitals. However, it is recognised that there is scope to combine population-based funding at area/region level, with case payment to individual agencies.

Attitude to Health↗
PubMedDate not supplied

Bi-national assessment of the Great Lakes: SOLEC partnerships.

Many administrative jurisdictions have authority over parts of the Great Lakes, sometimes with competing purposes as well as governance at differing scales of time and space. As demand increases for high quality information that is relevant to environmental managers, environmental and natural resource agencies with limited budgets must look to interdisciplinary, collaborative approaches for the collection, analysis and reporting of data. The State of the Lakes Ecosystem Conferences (SOLEC) were begun in 1994 in response to reporting requirements of the Great Lakes Water Quality Agreement between Canada and the U.S. The biennial conferences provide independent, science-based reporting on the state of health of the Great Lakes ecosystem components. A suite of indicators necessary and sufficient to assess Great Lakes ecosystem status was introduced in 1998. and assessments based on a subset of the indicators were presented in 2000. Because SOLEC is a multi-agency, multi-jurisdictional reporting venue, the SOLEC indicators require acceptance by a broad spectrum of stakeholders in the Great Lakes basin. The SOLEC indicators list is expected to provide the basis for government agencies and other organizations to collaborate more effectively and to allocate resources to data collection, evaluation and reporting on the state of the Great Lakes basin ecosystem.

Canada↗
PubMedDate not supplied

Issues related to disability in India: a focus group study.

BACKGROUND: Systematic research into disability has been scarce, especially from India, even though an estimated 5% of the population may have significant disability due to physical disorders. Depression as a common psychiatric disorder affects about 3%-5% of the population. Thus, the impact of disability related to physical, mental and substance use disorders is enormous and it influences resource allocation and policy planning. METHODS: The issues relating to disability were addressed through a qualitative multicentered study. Focus groups were conducted at three sites in Chennai, Bangalore and Delhi on three themes: (i) parity, stigmatization and social participation; (ii) current practices and needs; and (iii) the General Disability Model as proposed by the World Health Organization. The focus groups were homogeneous and included members from six categories of participants: individuals with physical disability, individuals with mental disability, individuals with alcohol/drug-related disability, family members of mentally disabled persons, family members of physically disabled persons and health professionals. In all, 118 groups were conducted with a mean (SD) group size of 8.6 (1.6). RESULTS: Patients with mental and alcohol/drug-related disability were more discriminated against than those with physical disability. Awareness regarding the existing laws and social programmes was uniformly poor across the three centres. Stigmatization was a major reason for under-utilization of the meagre resources available. There was poor awareness of the Disability Act, 1996. The consumers felt more comfortable with the earlier terms of 'handicap' and 'impairment'. CONCLUSIONS: The study has implications for policy planning, clinical decision-making and social behaviour. Awareness of the laws, facilities and programmes needs to be increased, especially regarding the Disability Act, 1996 among consumers as well as health professionals. More disability-friendly facilities are required.

Disability Evaluation↗
PubMed2006

Responses of Caragana korshinskii to different aboveground shoot removal: combining defence and tolerance strategies.

BACKGROUND AND AIMS: It is generally assumed that plants respond to natural enemies by either allocating resources to resistance traits or compensating for damage. This study evaluated how different methods of artificial shoot removal influence two alternative strategies (i.e. tolerance and defence) of Caragana korshinskii in the semi-arid area of China. METHODS: Zero per cent (control), 30% (30%) and 60% (60%) of the main shoot length and 25% (25%), 50% (50%) and 100% (100%) of the numbers of main shoots were removed from shrubs. KEY RESULTS: Moderate clipping treatments [30% removal of partial shoot length (RSL), 25% removal of shoot number (RSN) and 50% RSN] improved seed production, whereas the most intensive clipping treatments (60% RSL and 100% RSN) with most or total removal of potential flower buds reduced current reproduction fitness compared with controls. All treatments produced a similar leaf phenolic content, with the exception of 100% RSN which resulted in a low leaf phenolic content. In spite of a substantial investment in regrowth, clipped plants increased biomass allocation to physical defence. Control plants almost did not grow, had lower levels of physical defence and a lower photosynthetic rate, mobilized fewer carbohydrates from roots and produced more flowers. However, their current fitness was lower than that of plants undergoing clipping treatments (30% RSL, 25% RSN and 50% RSN) because of the high level of abortion of flowers and fruits. CONCLUSIONS: Caragana korshinskii responded to aboveground shoot removal through combining defence and tolerance strategies.

Biomass↗
PubMed1999

Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer.

BACKGROUND: Determining the apportionment of costs of cancer care and identifying factors that predict costs are important for planning ethical resource allocation for cancer care, especially in markets where managed care has grown. DESIGN: This study linked tumor registry data with Medicare administrative claims to determine the costs of care for breast, colorectal, lung and prostate cancers during the initial year subsequent to diagnosis, and to develop models to identify factors predicting costs. SUBJECTS: Patients with a diagnosis of breast (n = 1,952), colorectal (n = 2,563), lung (n = 3,331) or prostate cancer (n = 3,179) diagnosed from 1985 through 1988. RESULTS: The average costs during the initial treatment period were $12,141 (s.d. = $10,434) for breast cancer, $24,910 (s.d. = $14,870) for colorectal cancer, $21,351 (s.d. = $14,813) for lung cancer, and $14,361 (s.d. = $11,216) for prostate cancer. Using least squares regression analysis, factors significantly associated with cost included comorbidity, hospital length of stay, type of therapy, and ZIP level income for all four cancer sites. Access to health care resources was variably associated with costs of care. Total R2 ranged from 38% (prostate) to 49% (breast). The prediction error for the regression models ranged from < 1% to 4%, by cancer site. CONCLUSIONS: Linking administrative claims with state tumor registry data can accurately predict costs of cancer care during the first year subsequent to diagnosis for cancer patients. Regression models using both data sources may be useful to health plans and providers and in determining appropriate prospective reimbursement for cancer, particularly with increasing HMO penetration and decreased ability to capture complete and accurate utilization and cost data on this population.

Aged↗
PubMed2001

A bibliography of cost-effectiveness practices in physical medicine and rehabilitation: AAPM&R white paper.

Cost-effectiveness studies attempt to determine the ratio of costs to outcomes of a particular intervention or treatment and to compare a standard intervention with an alternative intervention to determine if the alternative is more cost effective. The goal is to establish priorities for the resources allocation and to decide among alternative interventions for the same medical condition. The global process of rehabilitation does not usually lend itself to cost-effective analysis (due to the complex set of treatments provided) but rather to specific interventions and specific aspects of outcome. The American Academy of Physical Medicine and Rehabilitation has published a cost effectiveness annotated bibliography on the Internet (http://www.aapmr.org/memphys/cebfinala.htm) that identifies 132 studies in the literature that meet specified criteria and are related to the field of rehabilitation. This White Paper attempts to interpret and synthesize the studies in that bibliography that relate to stroke, spinal cord injury (SCI), orthopedic conditions, pain syndromes, amputations, and traumatic brain injury (TBI). Most studies support the cost effectiveness of care for stroke and SCI in dedicated units or centers rather than in a general medical unit. Studies also support back programs and revascularization procedures in limb ischemia. Studies in TBI underscore the significant financial resources for the care of these patients as well as the potential benefit from rehabilitation services even in the most severely injured. Further high quality research in this area is needed.

Academies and Institutes↗
PubMed2006

Basing policy on evidence: low HIV, STIs, and risk behaviour in Dili, East Timor argue for more focused interventions.

BACKGROUND: East Timor is a newly independent, poor nation with many internally displaced people and foreign peace keeping forces. Similarities with Cambodia, which now has Asia's worst HIV epidemic, caused donors to earmark money for HIV prevention in East Timor, but no data were available to plan appropriate programmes. OBJECTIVES: To determine levels of infection with HIV and other sexually transmitted infections (STIs) and associated risk behaviours in Dili, East Timor, in order to guide resource allocation and appropriate prevention and care strategies. METHODS: In mid-2003, a cross sectional survey of female sex workers, men who have sex with men (MSM), taxi drivers, and soldiers was conducted. Participants provided biological specimens and all answered structured questionnaires. RESULTS: HIV prevalence was 3% among female sex workers (3/100), 0.9% among MSM (1/110), and zero in the other groups. All the HIV infected sex workers reported sex with foreign clients. Partner turnover reported by all groups was among the lowest in Asia, so was condom use. Access to basic HIV prevention services, including condoms and STI services, was extremely low in all groups. CONCLUSIONS: A few sex workers are infected with HIV in East Timor, but the virus is not circulating widely among their clients, and sexual networking is limited. The risk of a generalised HIV epidemic in East Timor is minimal. HIV can be contained by the provision of basic services to the small minority of the population at highest risk, preserving resources for other health and development needs.

Adult↗
PubMed1997

Economic analysis of respiratory rehabilitation.

STUDY OBJECTIVE: We report on the incremental costs associated with improvements in health-related quality of life (HRQL) following 6 months of respiratory rehabilitation compared with conventional community care. DESIGN: Prospective randomized controlled trial of rehabilitation. SETTING: A respiratory rehabilitation unit. PARTICIPANTS: Eighty-four subjects who completed the rehabilitation trial. INTERVENTION: Two months of inpatient rehabilitation followed by 4 months of outpatient supervision. MEASUREMENTS AND RESULTS: All costs (hospitalization, medical care, medications, home care, assistive devices, transportation) were included. Simultaneous allocation was used to determine capital and direct and indirect hospitalization costs. The incremental cost of achieving improvements beyond the minimal clinically important difference in dyspnea, emotional function, and mastery was $11,597 (Canadian). More than 90% of this cost was attributable to the inpatient phase of the program. Of the nonphysician health-care professionals, nursing was identified as the largest cost center, followed by physical therapy and occupational therapy. The number of subjects needed to be treated (NNT) to improve one subject was 4.1 for dyspnea, 4.4 for fatigue, 3.3 for emotion, and 2.5 for mastery. CONCLUSION: Cost estimates of various approaches to rehabilitation should be combined with valid, reliable, and responsive measures of outcome to enable cost-effectiveness measures to be reported. Comparison studies with the same method are necessary to determine whether the improvements in HRQL that follow inpatient rehabilitation are cheap or expensive. Such information will be important in identifying the extent to which alternative approaches to rehabilitation can influence resource allocation. A consideration of cost-effectiveness from the perspective of NNT may be useful in the evaluation of health-care programs.

Aged↗
PubMed1998

Resource requirements to develop a large, remote aboriginal health service: whose responsibility?

In 1994 the Commonwealth funded studies to establish and develop Aboriginal health services. One such study was undertaken in 1995 at Maningrida, Northern Territory: to identify the health-service needs of the population and consider community management structures; to identify Northern Territory expenditure for primary health care; and to provide a three- to five-year development budget. Approximately 2100 Aboriginal residents in the region used the service, including 750 living on 24 outstations within 75 km. Nearly 40 per cent were aged under 15 years. Childhood morbidity was high, with children under two averaging 1.4 hospital admissions per year. The age pyramid reflected premature adult mortality from the third decade of life. Service providers identified inadequate staffing and infrastructure as barriers to service development. Community consultations emphasised the need for resident doctors, improved outstation services and aged and respite care, local training for Aboriginal health workers and housing for staff. These developments would require per capita primary health care expenditure ($872) to be doubled. Aboriginal people in remote areas are disadvantaged through Commonwealth Grants Commission funding formulae and lack of Medicare access. As the sole funding source, the Northern Territory spends over $1.83 million per year providing health services at Maningrida. Additionally, the study proposed that the Commonwealth spend $1.96 million a year over five years on staffing and infrastructure. Local Aboriginal organisations also agreed to allocate resources for health service development. Ineffective implementation, lack of clarification of government responsibilities and funding shortfalls remain barriers to developing remote Aboriginal health services.

Adolescent↗
PubMed1987

Reviewing RAWP. Is the medical service increment for teaching (SIFT) adequate?

One issue of interest to the current review of the Resource Allocation Working Party (RAWP) formula is the extra service costs associated with medical teaching. RAWP intended the medical service increment for teaching (SIFT) to cover these costs. Although it is not possible to assess from the methods used to derive the SIFT rate whether it is or is not overgenerous for its intended purpose, the "excellence" elements of teaching hospitals tend to be protected. The financial problems of the teaching hospitals are more likely to be due to the relatively high use of services by local residents. But cutting services of London teaching hospitals to bring this use down to equitable levels may impair their capacity to train medical students.

Health Resources↗
PubMed1999

Socioeconomic risk factors and population-based regional allocation of healthcare funds.

Using the notion of professional uncertainty a population-based proxy need measure for hospital services was developed. Its relationship with socioeconomic variables and Standardized Mortality Ratios (SMR) was investigated in an attempt to develop an adjustment factor for socioeconomic risk factors beyond age-sex adjustment to be used for a population-based healthcare funding formula for Alberta. The data used are 1990, 1991, 1992 vital statistics and hospital separation abstracts, 1991 census data and Refined Diagnosis Related Group (RDRG) case weights. Geographic units studied were the 26 federal electoral districts in Alberta using postal codes as a linkage geo-code between census and hospital utilization and death data. SMRs, age-sex standardized per capita hospital utilization and proxy need rates were derived and correlated with socioeconomic variables derived from the census files. It appears that the poor, the less educated and aboriginals need more hospital services than the affluent, employed and educated, confirming previous findings. The unemployed tend to need more but use fewer services while immigrants and non-white ethnics tend to need and use fewer services. The unemployed, less educated and non-white ethnics are associated with positive correlation with premature mortality (SMR based on deaths under age 75 years), while the employed, highly educated tend to live longer. In general SMRs have positive but very low correlations with utilization and need rates suggesting that SMRs should not be used for resource allocation. Stepwise multiple regression analyses showed that the percentages of unemployed, immigrants, non-whites, aboriginals and those with education less than grade 9 explain about 90% of the variation in age-sex standardized hospital utilization rates. Percentages of unemployed, non-white ethnics, residents with education less than grade 9 and aboriginals explained 71% of variations in age-sex standardized per capita proxy hospital service need measures. Based on the results of regression analyses, a SEAM (Socio-Economic Adjustment Multiplier) scale was developed for utilization (SEAM-U) and proxy needs (SEAM-N). In essence a SEAM is a set of relative value (RV) multipliers applicable to a provincial common per age-sex adjusted capita allocation value to account for the impact of socioeconomic risk factors on hospital service needs or utilization. Finally, the resulting regression equations derived from the 26 Federal electoral district data were applied to Alberta's health regions, regional SEAMs were derived, and the impact of such adjustment was assessed.

Alberta↗
PubMed1999

Willingness to pay as a measure of the benefits of mental health care.

BACKGROUND: Decision-makers would benefit from being able to plan and evaluate mental health care interventions or programmes on the basis of costs and consequences that are measured in the same unit of measurement (money being the most convenient). Monetized quantification of the consequences of alternative interventions could be subsequently incorporated into cost-benefit allocation decisions. AIM: This paper provides an overview of the policy and research context within which willingness-to-pay survey techniques are located, together with a review of the main approaches used to date. We also highlight key issues in the application of these techniques and indicate areas of mental health research and policy that could benefit from their introduction. METHOD: Willingness-to-pay survey techniques are reviewed, and issues concerning their validity and application in the context of cost-benefit analyses of mental health policies are discussed. DISCUSSION: Different survey methods are available for generating willingness-to-pay data, the most common being the contingent valuation approach. An assessment of the validity of data generated by these alternative techniques is vital in order to ensure that they are consistent with the notion of economic preferences and values. IMPLICATIONS: The generation of valid and meaningful data on the monetized value of mental health outcomes would provide decision-makers with an improved evidence-based framework for resource allocation.

Journal Article↗
PubMed2005

Pediatric sedation in North American children's hospitals: a survey of anesthesia providers.

BACKGROUND: Information about the existence and organization of pediatric sedation services in North America is not available. We conducted a survey to collect this information from anesthesiologists at pediatric institutions and to identify factors perceived as limiting the development of sedation services. METHOD: We electronically mailed a confidential survey about pediatric sedation practice to an attending anesthesiologist involved in pediatric sedation at 116 children's hospitals in the United States and Canada. We identified the institutions using Internet resources. Electronic mailing addresses were obtained from departmental websites, society membership directories and departmental administrators. Our follow-up for nonresponders was by a second e-mail and a telephone call. RESULTS: A total of 54 completed questionnaires were received, a response rate of 47%. Forty-nine (91%) were received from US hospitals, and the remainder from Canadian. Fifty percent of hospitals had a formal pediatric sedation service. Fifty-four percent utilized a 'mobile' provider model. Hospital credentialing for nonanesthesiologist providers varied between 66 and 76% for 'deep' and 'conscious' sedation, respectively. A nurse-physician provider combination was the most common, utilized in 59% of hospitals. Anesthesiologists were the sole sedation providers in 26% of institutions. Propofol was used regularly by nonanesthesiologists for sedation of nonintubated (42%) and intubated (63%) patients. Eighty-seven percent of institutions reported barriers to development of pediatric sedation services. The most common barrier was a shortage of providers, particularly anesthesiologists. CONCLUSIONS: Propofol use by nonanesthesiologists is common. Addressing the shortage of providers, and allocating resources for credentialing providers will encourage further development of pediatric sedation practice.

Anesthesia↗
PubMed2006

Responses to selection on phenoloxidase activity in yellow dung flies.

Maintaining an immune system is costly. Resource allocation to immunity should therefore trade off against other fitness components. Numerous studies have found phenotypic trade-offs after immune challenge, but few have investigated genetic correlations between immune components and other traits. Furthermore, empirical evidence for the costs of maintaining an innate immune system in the absence of challenges is rare. We examined responses to artificial selection on phenoloxidase (PO) activity, an important part of the insect innate defense against multicellular pathogens, in yellow dung flies, Scathophaga stercoraria (L.). After 15 generations of successful selection on PO activity, we measured reproductive characters: clutch size, egg hatching rates, adult emergence rates, and adult longevity. We found no evidence for negative genetic correlations between PO activity and reproduction. In fact, flies of lines selected for increased PO activity had larger first clutches, and flies of lines selected for decreased PO activity had smaller ones. However, flies from high-PO lines died earlier than did low-PO flies when no food was available; that is, there is a survival cost of running at high PO levels in the absence of challenge. Variation in resource acquisition or use may lead to positive genetic correlations between PO and fertility and fecundity. The negative correlation between PO and longevity under starvation may indicate that variation for resource acquisition is maintained by a cost of acquisition, based on a genotype-environment interaction.

Animals↗
PubMed2002

Is council tax valuation band a predictor of mortality?

BACKGROUND: All current UK indices of socio-economic status have inherent problems, especially those used to govern resource allocation to the health sphere. The search for improved markers continues: this study proposes and tests the possibility that Council Tax Valuation Band (CTVB) might match requirements. PRESENTATION OF THE HYPOTHESIS: To determine if there is an association between CTVB of final residence and mortality risk using the death registers of a UK general practice. TESTING THE HYPOTHESIS: Standardised death rates and odds ratios (ORs) for groups defined by CTVB of dwelling (A - H) were calculated using one in four denominator samples from the practice lists. Analyses were repeated three times - between number of deaths and CTVB of residence of deceased 1992 - 1994 inclusive, 1995 - 1997 inc., 1998 - 2000 inc. In 856 deaths there were consistent and significant differences in death rates between CTVBs: above average for bands A and B residents; below average for other band residents. There were significantly higher ORs for A, B residents who were female and who died prematurely (before average group life expectancy). IMPLICATIONS OF THE HYPOTHESIS: CTVB of final residence appears to be a proxy marker of mortality risk and could be a valuable indicator of health needs resource at household level. It is worthy of further exploration.

Aged↗
PubMed2001

Maximising health gain within available resources in the New Zealand public health system.

OBJECTIVE: to obtain intervention-condition-specific investment and disinvestment recommendations which optimise the potential for health gain from existing respiratory diseases resource expenditure; and to trial a health economics technique for this purpose, assessing its usefulness as a means of prioritising health services resource allocation. DESIGN: a programme budgeting and marginal analysis (PBMA) exercise drawing upon the expertise of an advisory group of clinicians, managers and consumer advocates, supported by health authority staff. SETTING: the Southern and Midland health regions in New Zealand which have populations of one million and seven hundred thousand respectively. HEALTH SYSTEM CONTEXT: publicly funded secondary care sector in which regional health authority (RHA) purchasers contract for services with health care providers. METHODS: available evidence on the marginal costs and benefits of services for respiratory diseases was examined by an advisory group who produced investment and disinvestment recommendations by consensus using agreed prioritisation criteria. RESULTS: A list of specific investment and disinvestment proposals. Implementation plans for a number of investments formed part of the business plans for both RHAs in 1997/1998. No disinvestments were planned. CONCLUSIONS: prioritisation methods like PBMA, which are explicit and rational, can produce defensible evidence-based recommendations with the additional benefit of the credibility and support of an expert advisory group. The process encourages co-operative working and may itself have enduring benefits. However, preparation and conduct of such exercises is resource intensive and requires careful planning. This exercise has provided valuable lessons for the conduct of future prioritisation work.

Delivery of Health Care↗
PubMed2006

Identifying perinatal risk factors for infant maltreatment: an ecological approach.

BACKGROUND: Child maltreatment and its consequences are a persistent problem throughout the world. Public health workers, human services officials, and others are interested in new and efficient ways to determine which geographic areas to target for intervention programs and resources. To improve assessment efforts, selected perinatal factors were examined, both individually and in various combinations, to determine if they are associated with increased risk of infant maltreatment. State of Georgia birth records and abuse and neglect data were analyzed using an area-based, ecological approach with the census tract as a surrogate for the community. Cartographic visualization suggested some correlation exists between risk factors and child maltreatment, so bivariate and multivariate regression were performed. The presence of spatial autocorrelation precluded the use of traditional ordinary least squares regression, therefore a spatial regression model coupled with maximum likelihood estimation was employed. RESULTS: Results indicate that all individual factors or their combinations are significantly associated with increased risk of infant maltreatment. The set of perinatal risk factors that best predicts infant maltreatment rates are: mother smoked during pregnancy, families with three or more siblings, maternal age less than 20 years, births to unmarried mothers, Medicaid beneficiaries, and inadequate prenatal care. CONCLUSION: This model enables public health to take a proactive stance, to reasonably predict areas where poor outcomes are likely to occur, and to therefore more efficiently allocate resources. U.S. states that routinely collect the variables the National Center for Health Statistics (NCHS) defines for birth certificates can easily identify areas that are at high risk for infant maltreatment. The authors recommend that agencies charged with reducing child maltreatment target communities that demonstrate the perinatal risks identified in this study.

Child Abuse↗