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PubMedDate not supplied

The ethical imperative in health services governance and management.

Increasingly, administrative and biomedical ethical issues affect decision making in health services organizations. Although the ethics of biomedical decision making affect governance and management, this article is limited to administrative ethics: fiduciary duty, conflicts of interest, confidential information, resource allocation, and consent. Those who govern and manage health services organizations face an ethical imperative: They are moral agents with an independent duty to protect patients and further their interests. This duty is separate from any existing between care givers--such as physicians--and patients. It may complement other relationships, but it is always present. This imperative will become more difficult to attain. The potential conflict between economic and patient interests lies close to the surface in the patient care relationship, and maintaining it undoubtedly will be exacerbated by competitive pressures. The ethical implications of this conflict for those who govern and manage health services organizations are enormous.

Confidentiality↗
PubMed2001

Mapping as a method for analysing policy response in the management of health services.

Health services are susceptible to changes in health need, resource allocation, public-health debates and health policies. Service mapping is considered a useful tool for analysing complex issues, monitoring changes over time and facilitating change. It also enables one to describe pathways of care and the relationships between services. This article centres on two projects--a London-wide project 'Service networks for HIV Care' and a local survey 'Mapping of HIV-related services for illicit drug users'--and demonstrates the usefulness of mapping for both studies. Mapping of service networks allowed exploration of a variety of connections between treatment centres, and led to recommendations for a model of HIV service networks across London. The mapping of HIV-related services for illicit drug users confirmed that the service provision was balanced in time, space and target groups, but also identified gaps showing that services were not very successful in attracting women and members of ethnic minority groups. It is clear from both studies that mapping provides an overview of existing services, describing details of services, their target groups or links. It can assist to monitor changes over time, to reconfigure services according to need, and to target resources where need becomes apparent. Mapping exercises also can be useful in identifying new areas for collaboration and interagency work.

Community Health Planning↗
PubMed1989

Time preference for health in cost-effectiveness analysis.

In program evaluation, should a predicted health status gain of 1 quality-adjusted life year (QALY) occurring 10 years from now be valued the same as a 1-QALY increase realizable 5 years from now? Or 1 year from now? If not, how should these future gains (or losses) be evaluated from a present-time perspective? Such questions arise frequently in cost-effectiveness analyses of disease prevention-health promotion programs. This report argues there are actually two distinct interpretations of time preference jointly relevant in many multiperiod program evaluations. 1) In ongoing programs where both present and future population cohorts are, in effect, vying for resources, decision makers must establish a relative social weighting of cohorts by specifying (now) the dollar worth of any unit QALY gain achievable in each. This is a problem of intergenerational equity in the resource allocation process. 2) Individuals, in any cohort, may possess a time preference for the sequence of events comprising their own multiperiod health outcomes. Current models, typically discounting future health gains to present value at some constant rate (r), can well accommodate the first interpretation but not (simultaneously) the second. In response, this report introduces a two-step evaluation procedure featuring the "scenario strategy," a holistic multiattribute preference approach to evaluating multiperiod health outcomes. It allows one to isolate statistically time preference effects at the individual or group level and to incorporate them naturally into the overall evaluation of multiperiod outcomes. A survey-based example and an appendix illustrate the main points.

Attitude to Health↗
PubMed2005

Sources of data for rural health research: development of an inventory of Canadian databases.

Secondary data sources can often be used to help address questions about the health status, health behavior, health resources allocation, and utilization of health services of rural Canadians. But the task of deciding which Canadian databases are amenable to rural health research remains a challenge. As part of a larger research project titled "Canada's Rural Communities: Understanding Rural Health and Its Determinants," an inventory of 51 Canadian databases that have the potential of being used for rural health research was compiled, and it continues to be maintained and updated. The websites maintained by two of Canada's leading statistical data centers were systematically searched, along with other published articles and national reports, to produce this inventory. The criteria used to determine which data sources to include in this inventory are: (1) databases containing data at the national level that can be accessed by researchers, (2) databases containing data that are relevant to a variety of rural health issues, and (3) databases containing data that could be partitioned into rural and non-rural geographies. Detailed information is available by searching the inventory of national rural health research-related databases through the internet (www.cranhr.ca) or by contacting the lead author of this article. This article examines some of the issues in developing this resource and demonstrates the usefulness of its contents to Canadian and other rural health researchers.

Canada↗
PubMed2001

Critical appraisal of clinical practice guidelines targeting chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is so prevalent that the endorsement of management strategies by professional organizations issuing clinical practice guidelines (CPGs) will likely influence the clinical and financial resources allocated to this condition. OBJECTIVES: To examine the content of and to critically appraise the CPGs targeting COPD. METHODS: We identified, through a MEDLINE search (from January 1990 to May 1999) and contacts with experts and professional organizations, the CPGs for the overall management of COPD. We assessed the guidelines according to an index of quality measuring 3 dimensions: the rigor of development, the context and content, and the extent to which the dissemination and implementation have been addressed. The recommendations were also examined and compared. RESULTS: Of the 15 CPGs we included, none was based on a systematic review of the literature. Two were independently reviewed before their release, 1 included strategies for dissemination and implementation, and 1 estimated the economic implications associated with its recommendations. The recommendations were often difficult to interpret (reviewers' agreement: kappa median, 0.41). When unanimity existed regarding the benefits of a given management modality (such as respiratory rehabilitation), discrepancies were often identified in the application of the recommendation. CONCLUSIONS: The methodological quality of CPGs targeting COPD is limited, and there are disparities among many of their recommendations. Despite there being several CPGs worldwide, there is a need for an evidence-based summary of the literature to serve as a resource for those who provide health care to individuals with COPD.

Evidence-Based Medicine↗
PubMed2002

Management by constraints: considering patient volume when adding medical staff to the emergency department.

BACKGROUND: The emergency department is one of the hospital's busiest facilities and is frequently described as a bottleneck. Management by constraint is a managerial methodology that helps to focus on the most critical issues by identifying such bottlenecks. Based on this theory, the benefit of adding medical staff may depend on whether or not physician availability is the bottleneck in the system. OBJECTIVE: To formulate a dynamic statistical model to forecast the need for allocating additional medical staff to improve the efficacy of work in the emergency department, taking into account patient volume. METHODS: The daily number of non-trauma admissions to the general ED was assessed for the period 1 January 1992 to 1 December 1995 using the hospital computerized database. The marginal benefit to shortening patient length of stay in the ED by adding a physician during the evening shift was examined for different patient volumes. Data were analyzed with the SAS software package using a Gross Linear Model. RESULTS: The addition of a physician to the ED staff from noon to midnight significantly shortened patient LOS: an average decrease of 6.61 minutes for 80-119 admissions (P < 0.001). However, for less than 80 or more than 120 admissions, adding a physician did not have a significant effect on LOS in the ED. CONCLUSIONS: The dynamic model formulated in this study shows that patient volume determines the effectiveness of investing manpower in the ED. Identifying bottleneck critical factors, as suggested by the theory of constraints, may be useful for planning and coordinating emergency services that operate under stressful and unpredictable conditions. Consideration of patient volume may also provide ED managers with a logical basis for staffing and resource allocation.

Analysis of Variance↗
PubMed2001

Blue calls--time for a change?

Prior alert via a landline telephone ("blue call") is commonly used to warn accident and emergency (A&E) departments of the impending arrival of a seriously ill or injured patient. There are no published indications for making such calls or validated protocols on message content. Submitted telephone information has the potential for distortion as it is passed through the control centre resulting in inappropriate resource allocation. This study focuses on the quality and content of the message in the context of the available patient details as well as reviewing the clinical indications for the call. Data were collected on patients for whom "blue calls" were made to an A&E department over three months of 1998. Patients with life threatening conditions who were brought by non-blue light ambulance were identified during the same period. Similar details were collected on these critical patients. Of the 189 "blue calls" with complete details, 73% were admitted, (12% to ITU) and 18% died. Sixty nine per cent of cases were medical, 26% trauma and 5% obstetric. Pre-hospital observations were missing for 25% of patients (excluding patients in cardiac arrest), suggesting that the decisions to make a pre-alert call may have been based on subjective criteria in a significant minority. Information given over the telephone invariably included age, sex and presenting complaint but details of the current condition of the patient were included in only 11%. On reviewing pre-hospital information, a consultant in A&E and an ambulance paramedic judged that a prior alert was justified in 93% but additional information would be helpful in 52% of cases to correctly mobilise resources. Seventy five "clinically critical" patients were found in the three months of the study. Clinically critical patients were patients who had no prior alert, transported by ambulance, who were subsequently admitted to intensive care, theatre, or other high dependency areas. They included 27 patients with symptoms of a myocardial infarction. These patients may have benefited from prior alert. A protocol is suggested to provide criteria for making a prior alert to the A&E department via a landline connection. A standardised message structure would be used using vital signs and mechanism of injury or type of illness to assist in hospital preparation.

Adolescent↗
PubMed1989

Relation between all cause standardised mortality ratios and two indices of deprivation at regional and district level in England.

The use of mortality data in the form of standardised mortality ratios (SMRs) to measure the need for health care resources in the Resource Allocation Working Party (RAWP) formula in England has been criticised for underestimating the wider effects of adverse socioeconomic conditions on need, particularly in inner city areas. To assess this criticism, we explored the relationships at NHS Regional and District levels in England between two indicators of illness from the 1981 Census, two contrasting indices of deprivation based on the 1981 Census (the Jarman 8 Underprivileged Area (UPA) score and Townsend's Index of Material Deprivation) and their constituent variables, and all cause SMRs for 1982-3. All cause SMRs were highly correlated at Regional and District level with permanent and temporary sickness rates. At Regional level, three of the Thames Regions showed relatively high deprivation scores in relation to their SMRs, in comparison to the remaining Regions where the relative level of deprivation closely matched the Region's mortality ranking. District level analyses of the relations between SMRs and the deprivation indices and their constituent variables showed that the Thames/non-Thames dichotomy was accounted for by the 14 Districts in inner London. These findings suggest that although there may be a prima facie case for including an allowance for deprivation in RAWP, it is still not clear how the deprivation variables available in the Census relate empirically to the need for additional health service resources. The analysis raises questions about the appropriate definition of need in this context and whether the Census is a suitable source for the construction of a deprivation weighting for use in national RAWP.

Community Health Services↗
PubMed2005

Conjoint analysis of preferences for cardiac risk assessment in primary care.

OBJECTIVES: Many evaluations underestimate the utility associated with diagnostic interventions by failing to capture the nonclinical value of diagnostic information. This is a cause of bias in resource allocation decisions. A study was undertaken to investigate preferences for the assessment of cardiac risk, testing the suitability of conjoint analysis, a multiattribute preference elicitation method, in the field of clinical diagnosis. METHODS: Two conjoint analysis models focusing on selected characteristics of cardiac risk assessment in asymptomatic patients 40-50 years of age were applied to elicit preferences for cardiac risk assessment from samples of general practitioners and the general public in the United Kingdom and Italy. Both models were based on rankings of alternative scenarios, and the results were analyzed using multivariate analysis of variance and an ordered probit model. RESULTS: In both countries, members of the public attached at least three times more importance to prognostic value (relative to clinical value) than did general practitioners. Significantly different patterns were found in the two countries with regard to other characteristics of the assessment. Variation within samples was partly associated with personal characteristics. CONCLUSIONS: Only a fraction of the value of cardiac risk assessment to individuals and physicians in this study was linked to health outcomes. The study confirmed the appropriateness and validity of conjoint analysis in the assessment of preferences for diagnostic interventions. A wider use of this technique might significantly strengthen the existing evidence-base for diagnostic interventions, leading to a more efficient use of health-care resources.

Adult↗
PubMed1987

Recurrent cost and public health care delivery: the other war in El Salvador.

This study analyzes the causes and effects of the persistent underfinancing of recurrent costs in the Ministry of Health (MOH) of El Salvador over the past decade. Causative factors identified and discussed include (1) a functionally unintegrated MOH structure--consisting of (a) the autonomous hospitals and (b) the remainder of the Ministry; (2) the functional isolation of the Ministry's planning department from its budgetary department; (3) the use of historical-budget based decision-making--in lieu of more explicitly goal oriented resource allocation and planning criteria; (4) donor agencies' funding of infrastructure construction projects, coupled with their unwillingness to financially support the recurrent costs such projects ultimately give rise to; and finally, (5) the civil war and its associated economic dislocation, altered central government funding priorities and general state of disarray. The effects of persistent underfinancing of recurrent costs in El Salvador are the growing proportion of the MOH budget being consumed by outlays for personnel at the expense of virtually all other budgetary categories; the shortages of drugs and general medical supplies in public health facilities; and reduced levels of utilization of those facilities from what would otherwise be expected; all of which together imply a reduced level of both productivity and effectiveness of the public health care system. Policy implications and recommendations are briefly noted.

Budgets↗
PubMed2006

Heavy use of acute in-patient psychiatric services: the challenge to translate a utilization pattern into service provision.

OBJECTIVE: There is an inequality in resource utilization among acute psychiatric in-patients. About 20-30% of them absorb 60-80% of the total resources allocated to this form of treatment. This study intends to summarize findings related to heavy in-patient service use and to illustrate them by means of utilization data for acute psychiatric wards. METHOD: Longitudinal assessment of consecutive acute in-patients hospitalized for the first time. Analysis of individual utilization patterns by using latent class cluster analysis. RESULTS: Four groups with different utilization patterns were found all including heavy service users. In most cases heavy service use was temporary and could only be poorly predicted. CONCLUSION: Specific preventive interventions to contain heavy service use seem to be out of reach for the majority of high utilizing patients. However, services that have proven effective in reducing admissions to in-patient treatment and length of stay may nevertheless help to reduce heavy service use.

Acute Disease↗
PubMed2006

Reconciling salvage logging of boreal forests with a tural-disturbance management model.

In North American boreal forests, wildfire is the dominant agent of natural disturbance. A natural-disturbance model has therefore been promoted as an ecologically based approach to forest harvesting in these systems. Given accelerating resource demands, fire competes with harvest for timber and there is increasing pressure to salvage naturally burned areas. This creates a management paradox: simultaneous promotion of natural disturbance as a guide to sustainability while salvaging forests that have been naturally disturbed. The major drivers of postfire salvage in Canadian boreal forests are societal perceptions, overallocation of forest resources, and economic and policy incentives, and postfire salvage compromisesforest sustainability by diminishing the role of fire as a critical, natural process. These factors might be reconciled through consideration of fire in resource allocations and application of active adaptive management. We provide novel treatment of the role of burn severity in mediating biotic response by examining its influence on the amount, type, and distribution of live, postfire residual material, and we highlight the role of fire in shaping spatial and temporal patterns in forest biodiversity. Maintenance of natural postfire forests is a critical component of an ecosystem-based approach to forest management in boreal systems. Nevertheless, presentpracticesfocus heavily on expediting removal of timber from burned forests, despite increasing evidence that postfire communities differ markedly from postharvest systems, and there is a mismatch between emerging management models and past management practices. Policies that recognize the critical role of fire in these systems and facilitate enhanced understanding of natural system dynamics in support of development of sustainable management practices are urgently needed.

Biodiversity↗
PubMed2004

The generation gap: differences between children and adults pertinent to economic evaluations of health interventions.

Differences between children and adults have both technical and ethical implications for the design, interpretation and employment of economic analyses of health-related programmes. Even though policy makers increasingly turn to economic analyses to inform decisions about resource allocation, pertinent child-adult differences have received fragmented discussion in leading methodological references. Key areas warranting attention include: the ways in which a child's distinctive biology modifies the cost and effectiveness of healthcare interventions; challenges in assessing utilities for infants and young children given their limited but developing cognitive capacity; how a child's age, dependency and disability affect the selection of the appropriate time horizon and scope of the analysis; whether a child's non-wage earning productivity should be incorporated into analyses, and if so, what metric to use; what principles of equity policy makers should employ in using economic evaluations to choose between child- and adult-focused interventions; and whether special protective measures should be introduced to secure the rights and interests of children who cannot advocate for themselves.

Adult↗
PubMed2000

Needs assessment in primary care: general practitioners' perceptions and implications for the future.

BACKGROUND: Health needs assessment can guide the appropriate shift to primary care by identifying the most effective and efficient resource allocation to meet the needs of populations. Assessing health care needs will be a continuing challenge for primary care trusts in Scotland (or equivalent groups in other parts of the United Kingdom); however, lessons must be learned from the experience of needs assessment that followed the 'internal market' reforms of the 1990s. AIM: To examine general practitioners' (GPs') awareness and experience of needs assessment, to identify barriers to needs assessment in primary care, and to ascertain how better progress might be made in the future. METHOD: A postal questionnaire survey of 1777 Scottish GPs (a one-in-two sample) was combined with a semistructured interview survey of 'lead' GPs from a random sample of 64 mainland Scottish practices between May and August 1996. RESULTS: Sixty-five per cent (1154) of GPs responded to the questionnaire, of which 54% (965) were completed. Over 73% (47) of interviews were completed. Most GPs were unfamiliar with the concept of needs assessment and there was no evidence that needs assessment had influenced commissioning decisions. Most GPs argued that it was not a 'core' activity and that they lacked training in the relevant skills. While the attitude of the majority was indifferent, cynical, and sometimes hostile, a minority, comprising mostly younger fundholders, was more enthusiastic about needs assessment. CONCLUSION: The motivation and attitude of the majority of GPs present a barrier to needs assessment in primary care. GPs will require more resources and training if they are to undertake this responsibility. Most GPs believe than incentives (financial or organisational) will be necessary. Primary care trusts and equivalent structures should be aware of these attitudes as they seek to establish plans based on estimates of population needs in defined locations.

Adult↗
PubMed1998

The utility of polyglycolic acid mesh for abdominal access in patients with necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis is a poorly understood process that has been treated by a variety of surgical approaches. Despite advances in operative interventions and critical care, this disease often requires prolonged resource allocation and continues to cause substantial morbidity, with mortality rates ranging from 11% to 40%. We report on our recent series of patients with necrotizing pancreatitis and our experience with the use of an absorbable mesh in a subset of these patients to facilitate their surgical care. STUDY DESIGN: From 1985 to 1994, 40 patients with culture-proved necrotizing pancreatitis underwent operative debridement and drainage. Surgical outcomes were compared among patients who underwent a single debridement and drainage, those requiring multiple procedures, and those having placement of polyglycolic acid mesh. RESULTS: The overall hospital mortality rate was 30%. The mean length of hospital stay was 35 days. The rate of infected pancreatic necrosis was 60%, with a mortality rate of 45% in patients having infected pancreatic tissue at surgery. Patients without infected pancreatic tissue at surgery had a mortality rate of 6% (p = 0.03). Eleven patients requiring multiple operations had placement of absorbable polyglycolic acid mesh. Clinic followup was possible in five of six survivors who underwent mesh closure. Abdominal-wall hernias developed in two patients and were repaired electively, and three patients had spontaneous closure by granulation without abdominal-wall hernias. The average number of operations for debridement and drainage was 2.5 (range, 1-15). Patients with limited pancreatic necrosis required a single operative debridement and drainage, and this was associated with improved outcomes. CONCLUSIONS: Necrotizing pancreatitis remains an important challenge in surgical care. It requires prolonged hospitalization, costly resources, and causes substantial morbidity and mortality. Our patients with infected pancreatic necrosis or clinical deterioration underwent open staged necrosectomy and debridement. Those patients requiring repeat laparotomy often had placement of polyglycolic acid mesh. This provided open drainage of the abdominal cavity and simplified further care by allowing easy abdominal access for repeat drainage procedures, often performed in the intensive care unit. These patients had a high rate of fistula formation, which may be decreased by changes in wound care. Polyglycolic acid mesh is a useful adjunct in the surgical care of selected patients with necrotizing pancreatitis.

Abdominal Muscles↗
PubMed2004

Creating spatially defined databases for equitable health service planning in low-income countries: the example of Kenya.

Equity is an important criterion in evaluating health system performance. Developing a framework for equitable and effective resource allocation for health depends upon knowledge of service providers and their location in relation to the population they should serve. The last available map of health service providers in Kenya was developed in 1959. We have built a health service provider database from a variety of traditional government and opportunistic non-government sources and positioned spatially these facilities using global positioning systems, hand-drawn maps, topographical maps and other sources. Of 6674 identified service providers, 3355 (50%) were private sector, employer-provided or specialist facilities and only 39% were registered in the Kenyan Ministry of Health database during 2001. Of 3319 public service facilities supported by the Ministry of Health, missions, not-for-profit organizations and local authorities, 84% were registered on a Ministry of Health database and we were able to acquire co-ordinates for 92% of these. The ratio of public health services to population changed from 1:26,000 in 1959 to 1:9300 in 1999-2002. There were 82% of the population within 5 km of a public health facility and resident in 20% of the country. Our efforts to recreate a comprehensive, spatially defined list of health service providers has identified a number of weaknesses in existing national health management information systems, which with an increased commitment and minimal costs can be redressed. This will enable geographic information systems to exploit more fully facility-based morbidity data, population distribution and health access models to target resources and monitor the ability of health sector reforms to achieve equity in service provision.

Developing Countries↗
PubMed1978

Health service coverage and its evaluation.

Health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective. For the measurement of coverage, several key stages are first identified, each of them involving the realization of an important condition for providing the service; a coverage measure is then defined for each stage, namely the ratio between the number of people for whom the condition is met and the target population, so that a set of these measures represents the interaction between the service and the target population. This definition of coverage allows for variations, which are called "specific coverage", by limiting the target population to specific subgroups differentiated by certain conditions related to service provision or by demographic or socioeconomic factors.The evaluation of coverage on the basis of these concepts enables management to identify bottlenecks in the operation of the service, to analyse the constraining factors responsible for such bottlenecks, and to select effective measures for service development.

Cost-Benefit Analysis↗
PubMed1987

Financial incentives of subregional RAWP.

Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district's spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.

Health Resources↗