PubMed Health⌕ Search

Biomedical subjects

S Birch

Publications and source records attributed to S Birch.

At least 19 recordsLinked to original sources
PubMed1995

Does the community want devolved authority? Results of deliberative polling in Ontario.

OBJECTIVE: To obtain and contrast the informed opinions of people in five decision-making groups that could have a role in devolved governance of health care and social services. DESIGN: Deliberative polling. SETTING: Three rural and three urban communities selected from the 32 areas covered by a district health council in Ontario. PARTICIPANTS: A total of 280 citizens from five potential decision-making groups: randomly selected citizens, attendees at town-hall meetings, appointees to district health councils, elected officials and experts in health care and social services. INTERVENTION: Participants' opinions were polled during 29 structured 2-hour meetings. MAIN OUTCOME MEASURES: Participants' opinions on their personal willingness and their group's suitability to be involved in devolved decision making, desired type of decision-making involvement, information preferences, preferred areas of decision-making involvement and preferred composition of decision-making bodies. RESULTS: Mean attendance at each meeting was 9.6 citizens. Although there were some significant differences in opinion among the five potential decision-making groups, there were few differences among citizens from different geographic areas. A total of 189 (72%) of people polled were personally willing to take on a role involving responsibility for overall decision-making, but far fewer thought that their group was suited to taking on responsibility (30%) or a consulting role (55%). Elected officials were the most willing (85% personally willing, 50% thought their group was suitable) and randomly selected citizens the least willing (60% personally willing, 17% thought their group was suitable) to take responsibility for overall decision making. Most citizens polled indicated less interest in involvement in specific types of decisions, except for planning and setting priorities, than in overall decision making. Only 24 participants (9%) rated their own group as suitable to take responsibility for raising revenue, 91 (33%) deemed their group suited to distribution of funds and 108 (39%) felt their group was suitable for management of services. People in all five groups ranked health care needs (mean rank 1.5 out of four options) as the most important and preferences (mean rank 3.6) as the least important information. They rated a combination body involving several community groups as the most suitable overall decision-making body (8.8 on 10-point scale). Participants favoured the representation of elected officials, the provincial government and experts on combination bodies responsible for the specific types of decisions. Overall, as the complexity of devolved decision making became clear, participants tended to assign authority to traditional decision makers such as elected officials, experts and the provincial government, but also favoured a consulting role for attendees at town-hall meetings (i.e., interested citizens). CONCLUSION: There are significant differences among groups in the community in their willingness to be involved, desired roles and representation in devolved decision making on health care and social services in Ontario.

Adult↗
PubMed1995

Equity in health care: methodological contributions to the analysis of hospital utilization within Canada.

The main objective of this paper is to determine whether the distribution of hospital service utilization corresponds to the distribution of needs within Canada. This is accomplished by identifying the factors affecting the relationship between the incidence and quantity of hospital services and self-assessed need for such care in Canada. The data were derived from the General Social Survey (Statistics Canada, 1987) which is a weighted random sample of the Canadian population aged 15 and over. Employing methodological extensions over previous studies, the results indicate that although variation in quantity of hospital use is largely independent of income, household income has a significant positive effect on the incidence of hospital utilization. Additionally, variations in both incidence and quantity of use of hospital services are associated with variations in need and other factors within the model.

Adolescent↗
PubMed1995

Geographically-decentralized planning and management in health care: some informational issues and their implications for efficiency.

Geographically decentralized planning and management is an emerging theme within the health sector in many OECD countries. Advocates of decentralization argue that providing greater authority to local decision-making bodies can improve both the technical and allocative efficiency with which health care systems operate. Using concepts drawn from organizational theory and the economics of organizations, we examine the potential of centralized and decentralized planning and management structures to be efficient in light of the informational problems that must be overcome to allocate resources efficiently. We focus in particular on the need to integrate information regarding: (1) the effectiveness and efficiency of alternative clinical interventions and of alternative ways organize the delivery of health care; (2) the needs, values, and preferences in the population; and (3) local circumstances that affect delivery of care across regions. Informational concerns suggest that decentralized structures have greater potential to be efficient. We then briefly discuss some principles for the design of decentralized structures to aid in realizing these potential efficiency gains.

Decision Making, Organizational↗
PubMed1995

Preferences for outcomes in economic evaluation: an economic approach to addressing economic problems.

In this paper we critically appraise the appropriateness and validity from an economic perspective of alternative preference-based approaches to measuring outcomes in economic evaluations of health care interventions. We describe the properties of an outcome measure for economic evaluation to make it compatible with the principles of economics when applied to the problem of resource allocation. We also describe the difference and similarities between the psychometric and the economic approaches for the measurement of outcome. Using these properties we critically appraise the use of QALY and HYE methods of measuring individual and social preferences for health outcome. We argue that the most advanced measure currently available that meets these required properties is the HYE. Because the HYE, unlike the QALY, has its foundations in utility theory under uncertainty, it neither assumes particular formulations of the individual utility function, nor is it incompatible with the principles of economics. As such it represents a further stage in the continuing development of methods for economic evaluation of health care programmes.

Evaluation Studies as Topic↗
PubMed1995

A single-blind investigation of four auricular needle puncture configurations.

In order to identify an appropriate needle puncture control for clinical trials of acupuncture we conducted a study in which ten cocaine dependent subjects rated local and systemic effects of four auricular needle puncture configurations (a) sites commonly used for addiction; (b) sites proximate to addiction specific sites; (c) sites not specific for cocaine addiction; and (d) sites in the helix. Subjects received one treatment per day on four successive days. The addiction specific sites were rated highest on local effects; proximal sites a common control were rated highest on systemic effects. A majority of patients ranked the addiction specific sites as the most preferred treatment and the helix points as the least preferred. Results suggest that needle insertion into proximate and non-specific sites may be too active for use as controls; helix regions may be more suitable.

Acupuncture Points↗
PubMed1994

Dosimetric assessment of radiolabelled lipiodol as a potential therapeutic agent in colorectal liver metastases using combined CT and SPECT.

Lipiodol has previously been used as an agent for targeted radiotherapy by selective retention in primary hepatic tumours following direct hepatic arterial infusion. We have considered the potential dosimetry of 131I-labelled lipiodol in treating colorectal liver metastases. Fifteen patients with multiple colorectal liver metastases underwent selective hepatic angiography when 5 ml lipiodol labelled with 40 MBq 131I were infused. All patients underwent planar scintigraphy of the abdomen and thorax, single photon emission computed tomography (SPECT) of the liver and whole body counting on at least two occasions following lipiodol injection. Computed tomographic (CT) images of the liver were also taken typically 7 days postinjection. The lipiodol was found to deposit on the periphery of metastases of less than 10 cm diameter. In one patient a metastasis of diameter greater than 15 cm failed to infuse. In two patients the lobe of the liver containing metastases was not successfully infused. Overlay of CT and SPECT images confirmed concentration in metastases. Quantification of SPECT images indicated that between 55 and 100% (median 86%) of the injected activity was retained in the liver following injection, and tumour to liver ratios of dose delivered ranged from 1.21:1 to 4.7:1 (median 3.1:1). Tumour does ranged from 11.8 to 43.3 mGy MBq-1 injected. Dose to the lungs ranged from 0 to 46% of the liver dose (median 16%). Lipiodol has potential for treatment of colorectal liver metastases in targeted radiotherapy.

Colonic Neoplasms↗
PubMed1994

Pulmonary protein synthesis response to ozone.

1. Exposure to either 800 or 1200 ppb ozone for 6 h did not influence the content or activity of mouse lung ribosomal RNA; in consequence pulmonary protein synthesis pathways were not altered. 2. Increasing the exposure period to 24 h had a marked effect on protein metabolism which depended on the dose of ozone employed. A dose of 800 ppb resulted in a 17% increase in lung protein content. Since both lung ribosomal capacity and fractional synthesis rates were unchanged at this time, it is concluded that both a lower ribosomal activity and an increased protein degradation rate were responsible for the decrease in content. 3. Exposure to 1200 ppb ozone for 24 h, paradoxically resulted in increases in both the fractional (33%) and total (19%) protein synthetic rates. These responses were due to an increased pulmonary ribosomal efficiency in the lung at this time. 4. We conclude that, in the short term, reduced pulmonary synthetic capacity is not a component of ozone-induced lung injury, but rather, this important component of the repair mechanism, can be up-regulated in response to lung injury.

Animals↗
PubMed1994

Technology assessment in dentistry.

Technology, in the context of dental health care, is a term that can encompass systems such as water fluoridation, clinical procedures such as sealants, or clinical protocols such as antibiotic coverage of patients with a history of heart surgery. Similarly, the term technology assessment (TA) describes a multidisciplinary, scientific process established to guide policy on the adoption and distribution of health technologies. While this process is already well established in medicine, it is just beginning in dentistry. As such, TA is still evolving in dental care in terms of methods and process. TA is required to guide the content of curriculum and standards of practice in a rapidly changing dental environment. It should precede the adoption or deletion of both technologies and of writing practice guidelines. TA makes it possible to shed inappropriate technologies or the inappropriate application of existing technologies, which may free resources to pay for improvements in the dental care we offer.

Canada↗
PubMed1993

To each according to need: a community-based approach to allocating health care resources.

OBJECTIVE: To develop a method of allocating publicly funded health care resources among communities according to their relative levels of need for health care independent of their current patterns of use. DESIGN: For each health care program population mean levels of resource allocation were calculated and were adjusted for age and sex to produce a national age- and sex-adjusted share of program resources. Indices of relative need for health care (for most programs the standardized mortality ratio) were derived from existing data on aspects of illness and death and were then used to weight the age- and sex-adjusted shares for between-community differences in health risks and health care needs. SETTING: The populations of the 49 counties in Ontario were used as the communities among which resources were allocated. Health care expenditures in 1988-89 by the Ontario Ministry of Health were used as the "budget." MAIN RESULTS: Age- and sex-adjusted resource allocations weighted for between-community differences in health care needs differed from allocations based on population size, in certain cases by up to 100%. CONCLUSION: Existing data can be used to propose allocations of health care resources that relate to relative levels of need for care across communities.

Canada↗
PubMed1993

Guidelines for the adoption of new technologies: a prescription for uncontrolled growth in expenditures and how to avoid the problem.

The guidelines proposed by Laupacis and associates do not stem from economic theory and are a prescription for uncontrolled growth in health care expenditure. In particular, cost-effectiveness ratios provide information relevant to allocation decisions only in very special circumstances that do not usually apply in practice. When two interventions are compared a positive cost-effectiveness ratio (the common case) can tell us, at best, what additional costs will be incurred to generate the additional outcomes. From an economic perspective the information required to determine the attractiveness of a new technology is different: the source of the additional resource requirements must be identified and the opportunity cost of their redeployment estimated. Because the cost-effectiveness ratio (cost/-QALY) is sensitive to the method chosen to calculate QALYs, guidelines that do not specify (or justify) the appropriate method for calculating outcomes are unlikely to produce comparable results (or common yardsticks). In a health care system such as Canada's in which there is always pressure to introduce more effective technology, even if it is more costly, there is a risk of using such noncomparable data to justify adoption of particular technologies. The method of technology evaluation proposed by us is consistent with the stated goal of maximizing the community's health-related well-being for a given level of resources allocated to health care and ensures that new technologies are adopted only if this adoption represents an improvement in resource allocation.

Canada↗
PubMed1993

Equitable access to health care: methodological extensions to the analysis of physician utilization in Canada.

In this paper we analyse the distribution of family physician use in Canada to explore whether the stated goal of reasonable access to care has been achieved. We test hypotheses to see whether (a) variations in incidence and quantity of use are independent of need for care as proxied by self-assessed health status and (b) any observed relationship between variations in use and need is independent of other population characteristics. Previous research has conceptual, statistical and data limitations which bring into question the validity of the findings. These limitations are addressed by using more appropriate data, a conditional model for service utilization and correction for self-selectivity of users in the statistical analysis. Variations in need are identified as important and significant in explaining variations in both incidence and quantity of use with the estimated relationship between use and need being positive. Other population characteristics were found to be important and significant in explaining variations in use although household income is not among them. The relationship between use and need is associated with other variables including education, social support and region of residence. These findings suggest that analyses of utilization based on simple multivariate techniques and aggregate data can produce a picture of utilization that conceals important, policy relevant relationships while revealing other relationships that are essentially artifacts of inappropriate aggregation in ways which provide a false sense of achievement.

Adolescent↗
PubMed1993

Ozone exposure inhibits cardiac protein synthesis in the mouse.

Ozone is a major environmental oxidant pollutant. Following ozone inhalation, there are a number of marked pulmonary responses depending on the extent and duration of exposure. Recently it has been established that ozone exposure may also result in cardiac injury. In this study we show that exposure of mice to 800 ppb ozone for as little as 6 h results in a 16% decrease in cardiac protein synthesis rates (p < .02). The fall in protein synthesis is due primarily to a reduced rate of ribosomal efficiency (40%) in the hearts of ozone-exposed mice. This change in cardiac protein metabolism is accompanied by increased levels of two markers of tissue injury: edema and protein carbonyl content. It is unlikely, however, that these observations represent a direct action of ozone on the heart, but rather an indirect effect, possibly mediated by lipid peroxidation products generated in the lung.

Animals↗
PubMed1993

Is reasonable access what we want? Implications of, and challenges to, current Canadian policy on equity in health care.

Considerations of equity in the context of health care systems are often related closely to the presence or level of prices incurred by users of health care services. Some politicians and commentators have suggested that the removal of user charges under the Canadian health care system has led to equal access to care. But it is not clear that the equity principle inferred from these claims corresponds to the equity goals of current Canadian health policy. In this article the authors identify the precise equity principle that lies behind current health policy in Canada and consider the extent to which that principle is reflected in the performance of the system. They then consider other approaches to equity in health care in the context of the stated objectives of Canadian health policy and identify the implications of pursuing reasonable access in future health policy. The authors suggest that the implications of the current equity goals have not been recognized by policy makers, and if they were to be recognized it is not clear that they would be acceptable to Canadian populations and/or policy makers. Moreover, some of the implications would appear to be incompatible with other stated objectives of public policy.

Canada↗
PubMed1992

Biodistribution of Lipiodol following hepatic arterial injection.

Thirteen patients undergoing selective coeliac angiography before insertion of an indwelling hepatic arterial cannula underwent injection of 3 ml radiolabelled Lipiodol (2 MBq 131I) into the hepatic artery at the end of the procedure. At subsequent laparotomy 1-9 days later, biopsies were taken from normal liver and metastases. The radioactivity of this material was measured to establish the tumour:liver ratios. Two patients with large metastases (> 10 cm in diameter) had low ratios. In the remainder, the median ratio at 24 h was 1.5:1 (range 1.1-2.5:1; n = 5) and 2.6:1 (range 1.5-64.0:1; n = 6) at 3-9 days. Four patients underwent single photon emission computed tomography, which confirmed selective retention of Lipiodol in small metastases, although no activity was detected in a large deposit (> 15 cm) 10 days after injection. The tumour:liver ratio in the other three patients increased from 3.0-5.6:1 on day 1 to 4.5-7.2:1 on day 6. This study suggests that Lipiodol may be a useful therapeutic delivery agent to small colorectal liver metastases.

Humans↗
PubMed1992

Biodistribution of lipiodol following hepatic arterial injection.

Lipiodol, a derivative of poppy seed oil, has been used angiographically to improve visualisation of small liver tumours. We have utilised this finding to determine whether intrahepatic arterial injection of lipiodol can be used as a vehicle to deliver selectively 131I into liver tumours. Two groups of rats were studied. Group 1 (control, no liver tumour) received 0.1 ml 131I-lipiodol (1 microCi) into the hepatic artery. Animals were killed at regular time intervals over 30 days and organs were submitted to well-counting. Over 90% of activity remained in the liver at 6 h. Eighty per cent activity was lost from the normal liver, to be excreted in the urine over 30 days. Group 2 animals received intraportal injections of 7.5 x 10(5) MC28 sarcoma cells. Multiple liver metastases were present after 14 days. Animals were similarly studied at each time interval and samples from tumour and normal liver were submitted to well-counting. Lipiodol was selectively retained within tumour and cleared from normal liver. 131I-lipiodol may prove valuable as a delivery agent for radio/chemotherapy to liver metastases.

Animals↗
PubMed1991

Charging for health care: evidence on the utilisation of NHS prescribed drugs.

The effects of regular and frequent increases in charges for health care on patient utilisation are analysed using monthly data on National Health Service (NHS) prescribed drugs in England for the period 1979-1985. Using a partial adjustment model a utilisation equation of prescribed drugs is estimated for the adult non-elderly population that is subject to the NHS prescription charge. The maximum likelihood estimates of the coefficients of the equation imply that the charges policy followed in the U.K. has led to a significant reduction in utilisation among non-exempt patients. The short-run price elasticity of utilisation is -0.109 and the long-run elasticity is -0.09, while exempt utilisation is unaffected. Although the policy has generated a reduction in the central Government expenditure for prescribed drugs, on the basis of these estimates around 66% of these savings arise from the reduction in service use as opposed to the increased revenue per item of drugs.

Drug Prescriptions↗
PubMed1991

A needs-based methodology for allocating health care resources in Ontario, Canada: development and an application.

In an attempt to limit its health care expenditures, Ontario is, as one option, exploring the possibilities of a capitated system for service delivery payments as opposed to the present mixture of global budgets and fee-for-service. After reviewing the literatures on capitation (primarily American) and on resource allocation (primarily British), the paper sets out to establish a capitation rate, based on 'need' and not prior use, for a range of health services in the northern Ontarian community of Fort Frances-Rainy River. The difficulties and limitations of the needs-based approach are explored. The results reported show the setting of the local population characteristics against provincial average health care utilization data to generate expected use rates, which are then adjusted for need and other factors, particularly relative costs and sparsity. Finally these adjusted rates are applied to current provincial expenditures to derive a target share. This target is then expressed in relation to the planning population to derive the capitation rate.

Budgets↗