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N Daniels

Publications and source records attributed to N Daniels.

At least 19 recordsLinked to original sources
PubMed1996

The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine.

OBJECTIVE: To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative procedures for measuring and assigning values to resource use and health outcomes. CONSENSUS PROCESS: The panel met 11 times during 2 1/2 years with PHS staff and methodologists from federal agencies. Working groups brought issues and preliminary recommendations to the full panel for discussion. Draft recommendations were circulated to outside experts and the federal agencies prior to finalization. CONCLUSIONS: The panel's recommendations define a "reference case" cost-effectiveness analysis, a standard set of methods to serve as a point of comparison across studies. The reference case analysis is conducted from the societal perspective and accounts for benefits, harms, and costs to all parties. Although CEA does not reflect every element of importance in health care decisions, the information it provides is critical to informing decisions about the allocation of health care resources.

Advisory Committees↗
PubMed1995

The yin and yang of health care system reform. Professional and political strategies for setting limits.

President Clinton's proposed Health Security Act would establish a National Health Board (NHB) with three key functions. The NHB would (1) decide which services are "medically necessary or appropriate" (Title I, Subtitle B, Section 1154), (2) "recommend ... appropriate revisions (to the benefit package) ... to reflect changes in technology, health care needs, health care costs, and methods of service delivery" (Title I, Subtitle F, Section 1503, [a] [2]), and (3) "determine a national per capita baseline premium target" (Title VI, Subtitle A, Section 6002, [a]), thereby establishing a national health care budget. To date, including the work of Mrs Clinton's Task Force on Health Care System Reform, there has been little discussion of how the NHB would carry out these responsibilities. Critics claim that a budget cap would require rationing. Advocates counter that eliminating waste would make rationing unnecessary. In the imagined "testimony" that follows, we recommend two strategies to the NHB for carrying out its three key functions and for addressing the controversy about whether it should consider rationing.

Cost Control↗
PubMed1994

The articulation of values and principles involved in health care reform.

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing.

Advisory Committees↗
PubMed1992

HIV-infected professionals, patient rights, and the 'switching dilemma'.

The ethical issues surrounding the Centers for Disease Control and American Medical Association guidelines for health professionals infected with the human immunodeficiency virus are examined and discussed. Although human immunodeficiency virus transmission risks during surgery are lower than many risks we routinely face, it is not irrational for a patient to want to switch from an infected professional to an uninfected one. The American Medical Association claim that physicians have a duty to avoid imposing any identifiable risks is implausible. Knowing the Centers for Disease Control estimate of risks gives us no way to decide whether the rights of patients or those of handicapped (infected) workers should be given priority. Granting priority to patient rights, either by giving patients the opportunity to know the risks they face and to switch to another provider, or by removing infected providers (compulsory switching), makes us all worse off. This gives us reason to reject these guidelines and emphasize other infection control measures.

American Medical Association↗
PubMed1992

HIV-infected health care professionals: public threat or public sacrifice?

The ethical controversy surrounding the Centers for Disease Control (CDC) and American Medical Association (AMA) guidelines for restricting the practice of HIV-infected health professionals appears to hinge on whether we give priority to the rights of infected workers or patients. We cannot simply dismiss the concerns of patients as irrational, despite the low risks of transmission. Nor can we avoid the dispute about rights by claiming with the AMA that professionals have obligations to refrain from imposing "identifiable risks," however low, on patients. Nevertheless, allowing the full exercise of patient rights, either by giving patients the opportunity to know the risks they face and to switch providers, or by removing infected providers (compulsory switching), would make each of us worse off. This gives us adequate reason to reject these guidelines and to emphasize other infection control measures.

American Medical Association↗
PubMed1992

Running economy of elite male and elite female runners.

Twenty female and 45 male middle and long-distance runners, in training for the U.S. Olympic Trials, served as subjects. Ninety percent of both men and women subjects reached the Trials; eight women and 12 men qualified for the Olympic Games and five won medals. Each subject completed a VO2max and a series of submax treadmill runs, for the purpose of comparing heart rate (HR), VO2, and blood lactate (HLa) among men and women and among runners of various event specialties. Results showed the men to be taller, heavier, to have a lower six-site skinfold sum and a higher VO2max, than the women (P less than 0.05); there was no difference in age. When compared in running economy, men used less oxygen (ml.min-1.kg-1) at common absolute velocities, but VO2 (ml.km-1.kg-1) was not different between men and women at equal relative intensities (%VO2max). When men and women of equal VO2max were compared, the men were significantly more economical, using any method of comparison. Also, when comparisons of men and women of equal economy were made, it was found that the men had an even greater advantage over the "matched" women subjects than the mean VO2max comparison using all subjects. In looking at the SD (800-/1500-m runners), MD (3-K/5-K/10-K runners) and LD (marathon runners), it was found that the SD runners used the least oxygen (ml.min-1.kg-1) at speeds of marathon race pace and faster, but not at slower speeds. Men and women responded similarly in this regard. Running economy data for speeds slower than typical race paces, tended to show the LD runners to be most economical, suggesting that the speeds over which runners are tested plays an important part in determining which subjects are the most economical. It was concluded that at absolute running velocities, men are more economical than women, but when expressed in ml.km-1.kg-1 there are no gender differences at similar relative intensities of running. Also, when men and women of equal VO2max or equal economy are matched, the men show a better aerobic profile. It is recommended that economy data be collected up to speeds equal to over 90% VO2max.

Adult↗
PubMed1991

The nutritional habits of young adolescent swimmers.

Dietary food records from adolescent male and female swimmers participating in a national developmental training camp were analyzed for nutrient density. The mean caloric intake was 5,221.6 kcal for males and 3,572.6 kcal for females. The distribution of calories between carbohydrates, protein, and fat was not ideal for athletes trying to optimize performance. These young swimmers consumed too much fat and not enough carbohydrate. They consumed more than the RDA of vitamins A and C, and thiamine, riboflavin, and niacin; however, some concern is expressed for females who did not meet the RDA for calcium and iron. This study shows that although a group of adolescent swimmers may be consuming enough nutrients, individual swimmers may have very poor dietary habits and thus may not be providing adequate fuel or nutrients for optimal training or performance.

Adolescent↗
PubMed1990

Insurability and the HIV epidemic: ethical issues in underwriting.

The HIV epidemic has focused criticism on standard underwriting practices that exclude people with AIDS or at high risk for it from insurance coverage. Insurers have denied the charge that these practices are unfair, claiming instead that whatever is actuarially fair is fair or just. This defense will not work unless we assume that individuals are entitled to gain advantages and deserve losses merely as a result of their health status. That assumption is highly controversial at the level of theory and is inconsistent with many of our moral beliefs and practices, including our insurance practices. We should reject the insurers' argument. Justice in health care requires that we protect equality of opportunity, and that implies sharing the burden of protecting people against health risks. In a just healthcare system, whether mixed or purely public, the insurance scheme is in systematic terms actuarially unfair, for its overall social function must be to guarantee access to appropriate care. This does not mean that in our system insurers are ignoring their obligation to provide access to coverage. The obligation to assure access is primarily a social one, and the failures of access in our system are the result of public failures to meet those obligations. In a just but mixed system, there would be an explicit division of responsibility among public and private insurance schemes. In our mixed but unjust system, both legislators and insurers cynically pretend that the uninsured are the responsibility of the other. The attempt to treat actuarial fairness as a moral notion thus disguises what is really at issue, namely, the risk to insurers of adverse selection and the economic advantages of standard underwriting practices. Standard underwriting practices will be fair only if they are part of a just system, not if they simply are actuarially fair. The failure of the argument from actuarial fairness means that we must face an issue private insurers had hoped to avoid if we are to defend standard underwriting practices at all. In view of the clear risk that a mixed system will fail to assure access to care, the burden falls on defenders of a mixed system. They must show us that its social benefits outweigh its social costs, and that it is possible to have a mixed system that is not only just, but also is superior to a compulsory, universal insurance scheme.

Acquired Immunodeficiency Syndrome↗