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PubMed1986

Institutional subsidization of medical-school based continuing medical education.

The changing financial structure of health care is prompting review of medical school resources allocated to CME units. This study examined the types of subsidization provided to CME by medical schools and the methods of allocation of CME revenue within medical schools. Data are presented for 21 medical schools from different geographic areas of the United States. Medical schools often provide appreciable financial support to CME offices, particularly office space, faculty time, and space for CME meetings. However, the amount of support varies greatly from school to school. Revenue distribution arrangements also vary. Medical schools can use the description of arrangements at other schools in reviewing the appropriateness of their own current arrangements.

Data Collection↗

PubMed2006

Estimation of the optimal brachytherapy utilization rate in the treatment of carcinoma of the uterine cervix: review of clinical practice guidelines and primary evidence.

BACKGROUND: Brachytherapy (BT) is an integral part of cervical carcinoma treatment. There have been no attempts to estimate the optimal proportion of new cervical carcinoma cases that should be treated with BT, that is, the optimal rate of brachytherapy utilization (BTU). METHODS: Evidence-based guidelines and primary evidence were used to construct a BTU tree for carcinoma of the uterine cervix. Searches were performed of the epidemiological literature to ascertain the proportion of patients who fulfilled criteria for BT. The robustness of the model was tested by sensitivity analyses and by peer review. A patterns of care study of BT in New South Wales for 2003 was conducted, and actual BTU for cervical carcinoma determined. The differences between optimal and actual rates of BTU were assessed. RESULTS: The optimal cervical carcinoma BTU was 49% (range, 42% to 50%). In New South Wales in 2003, actual BTU was only 30% of 256 cervical carcinoma patients. The major discrepancy was for FIGO stage IB-IIA disease, where there was an underutilization of BT, estimated to be 15% actual use compared with 47% optimal use. In Surveillance, Epidemiology, and End Results (SEER) areas, there was underutilization for stage IB-IIA (22% actual BTU versus 47% optimal BTU) and for stage IIB-IVA (54% actual BTU versus 100% optimal BTU). CONCLUSIONS: BT for cervical carcinoma is underutilized in New South Wales and in SEER areas. The authors' model of optimal BTU can be used as a quality assurance tool to provide an evidence-based benchmark against which actual patterns of practice can be measured. The model can also be used to help determine adequacy of BT resource allocation.

Benchmarking↗

PubMed1991

Facilitating clinical trials. The expanding role of the nurse.

Clinical trials are becoming increasingly difficult to carry out in the face of a changing health care delivery system. The reluctance of third party payers to reimburse for experimental therapy and the growing practice of providers to limit resources allocated for the care of cancer patients undergoing such therapies seriously curtail the ability of investigators to test new cancer treatments clinically. In addition, certain beliefs, attitudes, and perceptions held by the public may interfere with patient case accrual. Nurses can help facilitate both accrual to and conduct of clinical research. This article addresses selected consumer- and provider-centered factors that inhibit clinical research. The expanding role of the nurse in the areas of public education, informed consent, direct care, and collaborative research is also described.

Attitude to Health↗

PubMed2006

Event-related potentials and visual avoidance in blood phobics: is there any attentional bias?

The possible presence of processing biases for threat-relevant information in blood-injection-injury phobia has been largely neglected in the literature. This issue was addressed by recording the late components (P300 and slow waves) of event-related potentials (ERPs) in the context of affective picture perception, as indicators of processing resources allocation. Blood phobics and healthy controls were shown threat-relevant, emotional threat-irrelevant, and neutral pictures. Free viewing time (VT) was measured as an index of voluntary visual avoidance, along with self-reports of pleasantness and arousal. No group differences as a function of picture content emerged for ERPs. Blood phobics spent less time viewing mutilations than did controls, but they did not show a clear-cut visual avoidance. As expected, individuals with phobias rated blood-related pictures as more unpleasant and arousing relative to controls. ERP results are in line with the limited behavioral data in the literature in demonstrating that blood phobics do not show an attentional bias toward threat-relevant stimuli.

Adult↗

PubMed2005

Needs assessment in dementia.

BACKGROUND: Resource allocation and service development traditionally focuses on diagnostic categories and consequent perceived need. Identification of the actual level of need in the elderly with dementia, and the degree to which it is unmet is necessary to plan services both individually and as a group. The aim of this study was to characterise the needs of a sample of community dwelling elderly patients with dementia who were referred to an old age psychiatry service in Ireland between July 2002 and July 2003. METHODOLOGY: Eighty-two consecutively referred community dwelling patients with ICD-10 diagnosis of dementia were assessed on The Care Needs Assessment Pack for Dementia (CareNap-D). Data on needs across seven domains (health and mobility, self-care and toileting, social interaction, thinking and memory, behaviour and mental state, housecare, community living) is presented (Reynolds T et al., 1998). RESULTS: Subjects had a mean of 33 (range: 13-56) identified needs. Approximately 1/3 of these were unmet with a mean of 13 (range: 0-37) and a mean of 20 (range: 4-39) were met. High levels of unmet need was identified in the domains of behaviour and mental state (84% of those with agitation) and of social interaction (79% of those with 'partaking in activities' need). The specific item of repetitive questioning occurred in 68 individuals and was unmet in 88% of these cases. Increasing age, lower MMSE score, and living alone were associated with greater total levels of unmet need. CONCLUSION: This data underlines the degree of unmet need in the community dwelling elderly with dementia and the importance of developing a spectrum of services on the basis of the actual needs identified.

Activities of Daily Living↗

PubMed2003

Are there inequities in the assessment of dementia under Japan's LTC insurance system?

BACKGROUND: Just two years after its inception, Japan's Long-term Care (LTC) insurance system is facing considerable criticism about whether or not it has developed a fair and appropriate way of allocating resources to the nation's disabled elderly population, especially those people with dementia. OBJECTIVE: The present study has investigated: (i) the relation of the Government-Certified Disability Index (GCDI) of the LTC insurance system to characteristics of people with dementia and their family caregivers; and (ii) whether the GCDI scores adequately reflect needs of people with DAT (dementia of Alzheimer's type) and VD (vascular-type dementia). METHODS: Subjects were assessed on their visits to outpatient clinics for their Activities of Daily Living (ADL), behavioural disturbances, MMSE, GCDI, service utilization and caregiver burden. Correlation analyses were conducted to examine the relationships among these variables, which were subsequently compared between the DAT and VD patients. RESULTS AND CONCLUSIONS: The GCDI was found to be associated with patients' ADLs and MMSE scores, and not with behavioural disturbances or caregiver burden. Compared to VD patients, people with DAT tended to have more behavioural disturbances but better ADL functioning. As a result, DAT patients were classified as 'less disabled' on their GCDI than VD patients, even though their caregivers felt as much burden as the caregivers of VD patients. These results show that the GCDI probably underestimates the impact of behaviour problems. Suggestions are made for a more balanced assessment of demented patients that is more consistent with their needs.

Activities of Daily Living↗

PubMed2005

The English National Health Service: 1979--2005.

This article aims to assess the development of the English National Health Service (NHS) over the period 1979--2005, against the original, and often repeated, core objectives of the system: that it be universal in offering coverage to all members of the population in times of health care need; that it be comprehensive in its provision of health care services; and that it be (largely) free at the point of use. Comprehensiveness is open to interpretation, and may depend upon the wealth of the nation. Universality and (largely) free care at the point of use, which lend themselves to the principle of equal access for equal need, are more concrete, and it is not difficult to ascertain if they have been substantially and/or systematically violated. The article details briefly the developments in resource allocation, provider payment mechanisms, incentives and accountability, and notes that much of the emphasis on health sector change since the mid 1980s has been placed upon improving supply side efficiency and reducing waiting lists/times. Improving NHS efficiency, and indeed related aspirations associated with choice and health outcomes, can be perceived as 'secondary' objectives, in that they should not serve to undermine the core objectives of the system, assuming that the security offered by having an accessible, universal health care system is considered worthy of protection. The overall conclusion is that the NHS has performed quite well against its core objectives to date, although it is possible that the current preoccupation with choice and health outcomes will lead us down a different policy path in the future.

Financial Management↗

PubMed2005

Analysing the Greek health system: a tale of fragmentation and inertia.

The Greek health system does not yet offer universal coverage and has fragmented funding and delivery. Funding is regressive, with a reliance on informal payments, and there are inequities in access, supply and quality of services. Inefficiencies arise from an over reliance on relatively expensive inputs, as evidenced by the oversupply of specialists and under-supply of nurses. Resource allocation mechanisms are historical and political with no relation to performance or output, therefore providers have little incentive to improve productivity. Some options for future health system reform include focusing on coordinating funding by developing a monopsony purchaser with the aim of improving quality of services and efficiency in the health system and changing provider incentives to improve productivity.

Delivery of Health Care↗

PubMed2005

Health care reform in Portugal: an evaluation of the NHS experience.

Since 1979, the Portuguese health care system has been based on a National Health Service structure that is expected to promote equity, efficiency, quality, accountability and the devolution of power. In this article, we analyse the content and impact of policies designed to reform the system between 1979 and 2002. This article differs from previous studies in that it uses a stage-based framework to evaluate the policy-making process and the impact of health care reform throughout different political cycles. We show that the NHS model has never been fully implemented and that many policies have diverted the system from its original objectives. Different governments have endorsed a progressive split between financing and provision and the institution of 'new public management' rules in public providers. We conclude that most policies put forward by Social Democratic governments have aimed at influencing demand, while Socialist governments have targeted the supply side. These policies have led to increases in health expenditure that have been comparatively more cost-shared by the State under Socialist governments. We show some overriding trends, namely as follows: despite huge improvements in health outcomes, the system is nonetheless lasting to meet its goals, particularly in terms of the equity of access and utilisation; accountability problems, inadequacies in the use of operational reforming tools (such as resource allocation mechanisms) and a lack of mechanisms to promote efficient behaviour, are all associated with cost containment problems. Structural reforms have been undertaken since 2002 and these have offered some potential for improving accountability and efficiency. Nonetheless, the success of these reforms calls for certain conditions that do not seem to have been fulfilled.

Financial Management↗

PubMed1992

Quality assurance in Canada: what are the health professions doing?

Although quality assurance (QA) programming in Canada is still at an early stage of development, health professionals are increasingly being called upon to substantiate the value of the services they provide. A body of research showing wide variations in the rates of service provision and significant amounts of inappropriate care have convinced many policy makers about the need to improve quality in the Canadian health system. Recent and severe economic pressures on provincial government funders could foster a more rational approach to resource allocation, including the consideration that better quality care is more efficient care. The bulk of health care in Canada is delivered in the private offices of practitioners, where quality assurance programming is relatively undeveloped. Although some licensing organizations do conduct proactive routine audits of their members' practices, a national survey, based on self-report, indicated that most of these programmes do not conform to recommendations found in the quality assurance literature. Although there have been some new initiatives in Canadian QA, it remains to be seen how these will influence the evolution of quality assurance programming conducted by Canada's health professions.

Canada↗

PubMed1993

Generalizability of valuations on health states collected with the EuroQolc-questionnaire.

PROBLEM: Non-response and non-usable response were found in population surveys on valuation of health states. If non-response is selective regarding valuations, then generalization of the resulting values to the whole survey population is not permitted. This could limit the use of empirical utility values in resource allocation in health care. METHODS: Response behaviour of a sample of 1400 from the Dutch general population to the mailed EuroQolc-questionnaire was analyzed by four methods. I. Phoning resolute non-respondents; II. comparison of zip code characteristics of respondents and non-respondents (because individual data on background characteristics were not available for the non-respondents); III. analysis of response over time (wave-analysis); IV: comparison of background variables of successful (less than two valuations missing) and unsuccessful respondents, combined with analysis of the effect of these background variables on valuations. RESULTS: No indications for selective non-response were found, although the phenomenon appeared hard to investigate. The successful response came from a slightly younger and better educated subsample. However, a general influence of age and educational level on valuations could not be shown. This finding is consistent with the literature. CONCLUSION: Although the existence of selective non-response cannot be excluded, its relevance can be considered to be small. This finding is encouraging for the use of empirical utility values in allocative decisions.

Adult↗

PubMedDate not supplied

Variations in general practice prescribing costs and implications for budget setting.

Indicative prescribing amounts, and the equivalent prescribing element of funds in the case of fund-holding practices, are now an established part of UK general practice. This paper examines the implications of variations in GP prescribing behaviour for the determination of prescribing budgets. Using regression analysis, the extent to which variations in total practice prescribing costs can be explained by factors suggested for inclusion in a weighted capitation formula is established. The results indicate that 97% of the variation in practice prescribing costs can be explained by differences in practice list size, the proportion of patients aged 65 years and over, the proportion of patients living in 'deprived areas' and whether or not the practice qualifies for 'inducement payments'. The implications of the results for budget setting are discussed. A resource allocation formula based on regression analysis of expenditures can be used to promote horizontal equity in terms of equal budgets for equal need. However, its implications for vertical equity and efficiency are more ambiguous.

Budgets↗

PubMed2003

A note on cost-value analysis.

We discuss 'cost-value analysis', a method for health care resource allocation suggested by Nord et al. (Nord E et al. Incorporating societal concerns for fairness in numerical valuations of health programmes. Health Econ 1999; 8: 25-39). Some difficulties and issues for future research are pointed out.

Cost-Benefit Analysis↗

PubMed2003

Methodological issues raised by preference-based approaches to measuring the health status of children.

This paper identifies and discusses a number of methodological issues that require consideration when applying preference-based approaches to the measurement of the health status of children. It is argued that the decision about which dimensions of health status to incorporate into health state descriptions or classifications should depend, in part, upon whether the measure will be used to inform resource allocation within or across age groups. In addition, the paper identifies and discusses a number of methodological issues surrounding the appropriate respondents for descriptions and valuations of health status in different contexts; potential sources of bias in the description and valuation processes; and the psychometric integrity of alternative measurement approaches.

Child↗

PubMed2004

Lack of multiplicative transitivity in person trade-off responses.

BACKGROUND: The person trade-off (PTO) is a technique for eliciting preferences for resource allocation across patient groups. In principle PTO responses should satisfy a requirement of multiplicative transitivity, i.e. that if people consider treatment of 1 in state A to be equivalent to treating 10 in state B, and 1 in state B to be equivalent to 10 in state C, then they should find 1 in state A equivalent to 100 in state C. Earlier studies addressing labelled diseases (specific diagnoses), have shown multiplicative intransitivity of the PTO responses. Our purpose was to test multiplicative transitivity in the case of health states described with the EuroQol instrument only and to find a possible framing effect such as the number of persons in the reference intervention. METHODS: Forty-four master degree students were asked to fill in a questionnaire addressing four chronic health states. Their task consisted in (1). ranking the states by severity, (2). valuing each of them by the means of the time trade-off, and (3). doing the PTO for all the 10 possible pairwise combinations of the four chronic states plus a fatal one. In a subsequent questionnaire the number of persons in the reference intervention in the PTO was increased from 10 to 100. Multiplicative transitivity was studied in subjects who demonstrated a willingness to trade off and consistency in ranking individual values. RESULTS: None of the 39 subjects included satisfied a minimum multiplicative transitivity requirement in PTO responses. Internal consistency was not improved when the PTO involved health states close to each other in terms of severity, nor when the prevention of death was not the reference intervention. For the 22 subjects having answered both types of questionnaire, increasing the number of persons in the reference intervention did not improve multiplicative transitivity. CONCLUSIONS: The PTO holds promise as a useful method for determining social preferences for priority setting, inasmuch as it captures distributive concerns that individual utility techniques such as the time trade-off do not address. But the lack of multiplicative transitivity in PTO responses is unsatisfactory, and ways to reduce this problem need to be explored.

Cost-Benefit Analysis↗

PubMedDate not supplied

Financing health care in the Sudan: some recent experiments in the central region.

The macroeconomic difficulties facing the developing countries are having a direct impact on these countries' public health programs. Reduced budgets and rising demands for health care are forcing health ministries to either cut back on already inadequate health care services or identify alternative sources of revenue. This article describes and analyzes a set of experiments designed and implemented by the Sudan's Central Province that have effectively raised the operating budget of the regional health ministry. The seven experiments encompass imposition of fees, cost containment efforts, and local taxes earmarked for health. Together, the revenue generating efforts have improved the efficiency of service delivery, ensured more efficient resource allocation, raised much needed revenue for the health system, and honored the government's commitment to make free health care available to the Sudanese population.

Costs and Cost Analysis↗

PubMedDate not supplied

Epidemiological measures in planning: observations from Sweden.

This article reviews how epidemiological measures can be used in health planning. Theoretical considerations are discussed together with empirical data from Sweden. Formulation of targets, priority settings, resource allocation and monitoring systems are some ways in which epidemiological data can improve health planning. One important lesson for planning is that problems related to health, inequalities in health, and access to care, must be made visible to politicians, health personnel and the public. Further, there is a need to complement a national health policy with a decentralized planning system that takes local conditions and needs into consideration.

Data Collection↗

PubMedDate not supplied

Central and local control in Nordic health care: the public organisation spectrum revised.

One of the distinguishing characteristics of national health care systems is the degree of public involvement in service provision, funding and policy making. In international comparisons the Nordic countries are usually seen as a uniform group. Yet, the countries do have important differences, and a descriptive model was sought to demonstrate these, and, at the same time, to differentiate the concept of public control. Using the central-local dichotomy, differences within the public framework were demonstrated between the countries, e.g. in methods of funding, financial regulation, formal planning instruments, and control of resource allocation. Financial control and planning were identified as two distinct components of public control. An analysis of the degree of centralisation along both dimensions separated the Nordic countries, which are otherwise homogenous as to public sector dominance.

Decision Making, Organizational↗