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Biomedical subjects

O F Norheim

Publications and source records attributed to O F Norheim.

At least 19 recordsLinked to original sources
PubMed2005

Responsibility in health care: a liberal egalitarian approach.

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as a criterion for the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments.

Choice Behavior↗
PubMed2004

Complicated deliveries, critical care and quality in emergency obstetric care in Northern Tanzania.

Our objective was to determine the availability and quality of obstetric care to improve resource allocation in northern Tanzania. We surveyed all facilities providing delivery services (n=129) in six districts in northern Tanzania using the UN Guidelines for monitoring emergency obstetric care (EmOC). The three last questions in this audit outline are examined: Are the right women (those with obstetric complications) using emergency obstetric care facilities (Met Need)? Are sufficient quantities of critical services being provided (cesarean section rate (CSR))? Is the quality of the services adequate (case fatality rate (CFR))? Complications are calculated using Plan 3 of the UN Guidelines to assess the value of routine data for EmOC indicator monitoring. Nearly 60% of the expected complicated deliveries in the study population were conducted at EmOC qualified health facilities. 81.2% of the expected complicated deliveries are conducted in any facility (including facilities not qualifying as EmOC facilities). There is an inadequate level of critical services provided (CSR 4.6). Voluntary agencies provide most of these services in rural settings. All indicators show large variations with the setting (urban/rural location, level and ownership of facilities). Finally, there is large variation in the CFR with only one facility meeting the minimum accepted level. Utilization and quality of critical obstetric services at lower levels and in rural districts must be improved. The potential for improving the resource allocation within lower levels of the health care system is discussed. Given the small number of qualified facilities yet relatively high Met Need, we argue that it is neither the mothers' ignorance nor their lack of ability to get to a facility that is the main barrier to receiving quality care when needed, but rather the lack of quality care at the facility. Little can be concluded using the CFR to describe the quality of services provided.

Critical Care↗
PubMed2003

Quantifying quality of life for economic analysis: time out for time tradeoff.

The "Time trade-off" (TTO), is the most widely used method to "quality adjust" life years for "QALYs" in cost utility analysis. In this paper we ask if it is theoretically likely that the TTO is valid for this use. The TTO consists in a trade off between longevity and quality of life. Firstly, we argue that it is impossible to control for all factors that may influence one's willingness to sacrifice lifetime. Secondly, that longevity and quality of life are too closely interrelated for the hypothetical trade off to reveal real preferences. Thirdly, that the TTO handles the value of a life year inconsistently because it simultaneously assumes that it changes (as an outcome measure) and that it doesn't change (as a currency unit). Lastly, we ask whether the difficulties stem from an inherent contradiction in trying to quantify quality of life. The problems theoretical validity an internal consistency, contrast the use of the results as exact measurements. We conclude that cost utility analysis based on TTO cannot be trusted as a tool for setting priorities in health.

Cost-Benefit Analysis↗
PubMed2001

[Knowledge must be combined with values for decision making in uncertainty].

On the basis of a clinical presentation of a woman with atrial fibrillation and diabetes mellitus, this article examines how medical evidence can be combined with patient preferences in the analysis of clinical choice. Such choices tend to be analysed and discussed without due consideration for patient or public values. It is argued that such an analysis is incomplete until the patient's preferences are incorporated into the model. This is also a way of implementing patient-centred medicine. We discuss how decision theory can be used to clarify clinical choices, sometimes with surprising results for the physician. How to handle situations when the patient's preferences are in conflict with the physician's judgement, is also discussed. It is concluded that good clinical practice must be based on evidence, but it should also take into account the patient's values in choices with uncertain outcomes.

Decision Making↗
PubMed2001

Adoption of new health care services in Norway (1993-1997): specialists' self-assessment according to national criteria for priority setting.

OBJECTIVES: To identify health care services adopted in Norway in the period 1993-1997, and examine them according to proposed national guidelines for priority setting. These guidelines define core services. DESIGN: Two-stage self-administered questionnaire. SETTING: The Norwegian public healthcare system. SUBJECTS: Presidents of all relevant specialist and sub-specialist associations in the Norwegian Medical Association (n=56). OUTCOME MEASURES: Number of adopted services satisfying the priority criteria of core services, according to physician's self-assessment. Number and type of interventions suited for the priority-setting criteria. RESULTS: Thirty-two percent of new technologies satisfied the definition of core services according to specialists' own assessment. Of the 88 responses analysed for the second stage of our survey, fifteen answers (17%) indicated lack of applicability of the priority setting criteria. Loss of applicability was related to diagnostic and procedure-related technologies. CONCLUSIONS: Less than one-half of the assessed technologies adopted in Norway in the period 1993-1997 satisfy proposed national criteria for priority setting. The guidelines are applicable for most interventions, but fail in most evaluations of diagnostic and procedure-related improvements. Independent and systematic evaluations of new technologies are needed within the context of priority setting.

Attitude of Health Personnel↗
PubMed2000

Limiting access to allogeneic bone marrow transplantation in five European countries: what can we learn about implicit rationing?

BACKGROUND: Allogeneic bone marrow transplantation is a complex procedure exemplifying a class of new and emerging treatment modalities involving advanced medical technologies with high costs. OBJECTIVES: To collect available data on volume of allogeneic bone marrow transplantation in five European countries for the period 1990-1994. To assess the opinion of selected physicians on whether they felt that patients that would have benefited from a transplant actually received a transplant in the same period. To assess their opinion on possible reasons for limited access. METHOD: Literature review and mailed self-administered questionnaire to the responsible physician at 76 transplant centres in Denmark, Germany, The Netherlands, Norway, and the UK. RESULTS: Substantial geographical differences in transplantation rates between the five countries studied. For adult patients 62.5% of the respondents felt that there was limited access to allogeneic bone marrow transplantation in the period. For children, the corresponding figure was 37.5%. The reasons for limited access cited most frequently were scarcity of facilities or transplant beds, scarcity of donors, and inadequate referral practices.

Adult↗
PubMed1999

Access to health care in the Scandinavian countries: ethical aspects.

The health care systems are fairly similar in the Scandinavian countries. The exact details vary, but in all three countries the system is almost exclusively publicly funded through taxation, and most (or all) hospitals are also publicly owned and managed. The countries also have a fairly strong primary care sector (even though it varies between the countries), with family physicians to various degrees acting as gatekeepers to specialist services. In Denmark most of the GP services are free. For the patient in Norway and Sweden there are out-of-pocket co-payments for GP consultations, with upper limits, but consultations for children are free. Hospital treatment is free in Denmark while the other countries use a system with out-of-pocket co-payment. There is a very strong public commitment to access to high quality health care for all. Solidarity and equality form the ideological basis for the Scandinavian welfare state. Means testing, for instance, has been widely rejected in the Scandinavian countries on the grounds that public services should not stigmatise any particular group. Solidarity also means devoting special consideration to the needs of those who have less chance than others of making their voices heard or exercising their rights. Issues of limited access are now, however, challenging the thinking about a health care system based on solidarity.

Delivery of Health Care↗
PubMed1998

[How shall we set priorities among experimental treatment methods?].

There is an increasing demand from patients to have access to new and promising treatment for severe diseases. Norway has recently started ordinary public funding of large-scale clinical investigation of treatment effect and safety for new treatment modalities. The government has thus established a new principle for funding a sub-category of clinical research: investigational medicine. How should we prioritize between promising clinical protocols when resources are scarce? The article examines criteria for priority setting in investigational medicine: quality of evidence; magnitude of expected benefit from treatment; balance between risks and benefits; quality of the research protocol; cost; and size of patient population. These criteria are applied on a controversial clinical examples, high-dose chemotherapy with hematopoietic stem cell support for metastatic breast cancer.

Antineoplastic Agents↗
PubMed1996

[Is liver transplantation a therapeutic possibility of low priority in Norway?].

The number of orthotopic liver transplantations per year in Norway is smaller than in other countries of Northern Europe. Relatively fewer liver transplantations are performed both in the case of accepted indications such as primary biliary cirrhosis and acute liver failure, and for more arguable indications like post viral cirrhosis and alcoholic liver disease. The authors discuss priorities in health care in Norway. The efficacy of liver transplantation for selected groups of patients is compared with the efficacy of bone marrow transplantation for another selected group of patients. If indications and activity of bone marrow transplantation depict the threshold of prioritization, then more patients with chronic liver disease should be offered liver transplantation as therapy.

Europe↗
PubMed1995

The Norwegian welfare state in transition: rationing and plurality of values as ethical challenges for the health care system.

This paper presents the Norwegian national health care system and the manner in which the problems of rationing and pluralism of values create new ethical and political challenges. The paper concludes with some doubts about the feasibility of the transformation taking place within this kind of health care system, with special reference to governmental control and consumer preferences.

Community Participation↗
PubMed1994

[Prioritization of fertilization in vitro--a systematic analysis].

Who should be offered medically assisted conception treatment within a public health care system? This article discusses medical and ethical selection criteria in relation to general political guidelines for prioritization. Our tentative conclusion is that it is possible to differentiate between groups of patients according to disease criteria, the severity of disease, medical efficacy and cost-efficiency. We note that there is a great need for data to enable well-founded decisions when prioritizing applicants for in vitro fertilization within a public health care system.

Cost-Benefit Analysis↗
PubMed1994

Equality, explicitness, severity, and rigidity: the Oregon plan evaluated from a Scandinavian perspective.

This article is an attempt to evaluate the Oregon plan from the perspective of a Scandinavian national health care system. The Nordic welfare states are marked by a strong emphasis on equality. As an example of an egalitarian system we present the Norwegian health care model in part one. In part two, the arguments in favor of a one tier system in Norway are presented and compared to Oregon's two tier system. Although we argue, in part three, that a comparison of the degree of explicitness in the prioritization process shows that Norway has much to learn from Oregon, we do believe that the Norwegian system has some attractive elements that may function as an important corrective. In part four we present the Norwegian Guidelines for priority-setting and discuss the weight assigned to the severity of disease criterion. It is argued that the exclusion of information about the severity of disease partly explains the counterintuitive ranking of treatment-condition pairs in Oregon's initial method based on the principle of health maximization. A normative analysis of the conflicting norms of efficiency and equality of results is called for. The final part of the paper is devoted to the problem of rigidity. Henry J. Aaron has argued that the Oregon system is insensitive to inter-individual variations within each diagnosis-treatment pair. This objection is a severe one, since the system might end up treating patients unfairly on the individual level. To overcome this problem, we suggest a selection rule that should be more capable of dealing with the problem of rigidity.

Community Participation↗
PubMed1993

[Prioritizing in hospital departments].

A framework for decision-making is introduced in which two out of five patients will be denied treatment. Certain resource constraints are accepted in this hypothetical example. The authors' own ranking of five patients from a department of internal medicine are presented. It was not difficult to select the highest prioritized patients. However, ranking of the remaining patients revealed considerable controversy. Emphasis is therefore laid on the reasons given for each ranking. An interesting finding is that variations in awarding priority to some cases are clearly based on disagreement about facts, not values. The article concludes by suggesting a classification of selection criteria for priority setting based on a distinction between necessary, controversial and unacceptable criteria. The article is presented in an attempt to stimulate a debate about priority setting in everyday hospital work.

Decision Making↗
PubMed1993

[Prioritizing and righteousness--what do we do when we can't do everything?].

This article considers the principles for allocating scarce resources in the health care sector. The author discusses the conflict between the utilitarian principle of welfare maximization and the norm of equality. It is argued that the goal of equal health may lead to the problem of "the bottomless pit". That is to say, an unreasonable amount of the total health care resources will be distributed to those with the most severe conditions. The utilitarian principle leads to a more efficient distribution of resources, but in some important cases may conflict with the concern for equality or the concern for those who are worst off. The problem seems to be that the norm of distributive efficiency and the norm of distributive equality are both relevant in society. John Broome's account of fairness as equal proportional satisfaction of legitimate claims is presented as an interesting approach to this problem. A classification of criteria is also presented as a general framework for a debate on the making of priorities in the clinical setting.

Health Care Rationing↗