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PubMedDate not supplied

New ways of financing and organizing health care in Sweden.

The health care system in Sweden has been undergoing radical change since 1991. The mainly public financed (90%) system with 26 autonomous counties spent 8.5% of its gross domestic product on health care in 1991. The main features of the 'paradigm shift' are: separation of production and financing; resource allocation to health districts in relation to the needs of the population; and introduction of public competition between health districts (purchasers) and hospitals (providers). The health district boards are responsible for the health care of the population in their district hospitals financed by their activities (e.g. through diagnosis-related groups (DRGs)) and quality aspects monitored by central authorities. A parliamentary committee (HSU 2000) is investigating how Sweden's health care system can be organized and financed in the future. Three models are analyzed: a reformed county council court model, a primary care-managed model, and a compulsory insurance model. Each model must be consistent with equity and public financing. From 1992 in the Stockholm county, five surgical specialties were paid for their activities according to DRGs for inpatient care and another system for outpatient care. The number of treated patients during 1992 increased by 8% in inpatient care, 50% in day surgery and by 15% in outpatient care. Taken together, the activities increased by 11%, which is slightly more than the expected 10% increase in productivity. (There was a 10% decrease in DRG prices from 1 January 1992.) The total costs decreased by 1% due to fewer personnel. Nothing has been reported concerning the quality of care, neither before nor after the model was introduced. From 1993, all somatic acute specialties are paid by DRGs and the equivalent outpatient classification systems. The results from 1993 will be presented in the autumn of 1994.

Cost-Benefit Analysis↗

PubMedDate not supplied

Financing indicators for health care decentralization in Latin America: information and suggestions for health planning.

This article presents the results from an evaluative longitudinal study with before-after design. The main objective was to determine the effects of health care decentralization on changes in health financing. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. Taking into account the changes implemented in the three countries, as well as the strengths and weaknesses of each country in financing and decentralization, a rule for decision-making is proposed that attempts to identify the main financial changes implemented in each country and the basic indicators that can be used in future years to direct the planning, assessment, adjustment and correction of health financing and decentralization.

Delivery of Health Care↗

PubMedDate not supplied

Applying DALY to assessing national health insurance performance: the relationship between the national health insurance expenditures and the burden of disease measures in Iran.

The Iranian government has considered using DALYs as an indicator to prioritize health service expenditures to reduce the burden of disease for the public. A cross-sectional study was designed to compare several measures of the burden of disease with the actual amounts of national health insurance (NHI) expenditures, in one province of Iran (Semnan) for a period of 2 months (September 2000 and February 2001). Furthermore, on the basis of the research findings, a questionnaire was designed and distributed to stakeholders at local and national levels to explore their ideas about the gap between the expenditures of the diseases group and their burden. A semi-structured interview was conducted to elicit participants' views on the research findings. The results of this study have revealed that, currently, there is no strong relation between the NHI expenditures and DALY (r = 0.41, p = 0.09), but that there are stronger relationships between the amounts of NHI reimbursements with YLL (r = 0.52, p < 0.05), mortality (r = 0.67, p < 0.01) and hospital days (r = 0.90, p < 0.01). Comparing each group of disorders' DALY with the resources allocated to them (cost per DALY) it was shown that diabetes mellitus, musculoskeletal diseases, maternal conditions, sense organ disorders received considerably generous funding; and, perinatal conditions, congenital abnormalities, nutritional deficiencies were relatively under-funded. The qualitative research results showed that the majority of respondents agreed that the differences presently existing between disorders' burden and NHI expenditures cannot be justified; and, further, that reducing the overall burden of disease must be one of the most important objectives for the NHI.

Attitude to Health↗

PubMed2004

Cervical cancer as a priority for prevention in different world regions: an evaluation using years of life lost.

The relative importance of cancer of the cervix among several important causes of mortality (from cancer and other diseases) has been evaluated by estimating the years of life lost (YLL) by young and middle-aged women (25-64 years old) in different regions of the world. The life years were weighted to reflect their importance to the individual and to society. On a global basis, cancer of the cervix is responsible for about 2% of the total (weighted) YLL, fewer than for other causes of mortality in this age group. However, it is the most important cause of YLL in Latin America and the Caribbean. It also makes the largest contribution to YLL from cancer in the populous regions of SubSaharan Africa and South-Central Asia where the actual risk of loss of life from this cause is higher, although overshadowed by noncancer deaths (from AIDS, TB and maternal conditions). The overall picture is not very sensitive to the age weighting function used. The fact that most of the loss of life is preventable, and that simple technologies have been developed that make this practicable, means that cervical cancer has an even higher profile from the perspective of resource allocation in low income settings.

Adult↗

PubMedDate not supplied

Quality of life in quadriplegic adults: a focus group study.

This article describes a study whose purpose was to provide additional information about the components of quality of life for quadriplegic individuals. A focus group technique was used to determine subjects' opinions about what constitutes an acceptable quality of life. Three focus groups with a total of 14 subjects met to discuss the topic. Transcripts of the interviews were analyzed to determine themes and to identify components of quality of life for these individuals. Findings indicate that the factors influencing quality of life for quadriplegics include inner strength/survival, finances, relationships, job/productivity, health, level of activity, assertiveness, and independence/dependence. These findings will provide health professionals and policymakers with information about what factors quadriplegics consider important to maintaining an acceptable quality of life. This knowledge is necessary for public policy development, resource allocation, and interventions that will enhance the quality of life for people affected by quadriplegia.

Activities of Daily Living↗

PubMedDate not supplied

Ethical conflicts reported by certified registered rehabilitation nurses.

The purpose of this study was to identify the types of ethical conflict reported by certified registered rehabilitation nurses (CRRNs) and their relationship to demographic, educational, and practice-setting variables. Ethical conflicts expressed by CRRNs in active practice in Maryland, Virginia, and the District of Columbia were analyzed according to four themes. Disagreements about medical or institutional practice, patients' rights, and payment issues were the most frequent practice contexts for ethical conflicts, reflecting these nurses' considerable underlying concerns about resource allocation in rehabilitation practice. Participants believed that 60% of the ethical conflicts were resolved, frequently through discussions with other team members and patients' family members. Ethics committees and consultants were used infrequently. There were no statistically significant relationships between the kinds of conflicts or their resolution and the participants' demographic, educational, and practice-setting variables.

Adult↗

PubMed1999

Prevalence of back, neck and shoulder problems in the inner city: implications for the provision of physiotherapy services in primary healthcare.

BACKGROUND AND PURPOSE: More general practitioners are offering physiotherapy services within primary healthcare; however, this provision may result in increased demand. Resource allocation, based on previous patterns of consultation for musculoskeletal conditions, may be inadequate since the need for treatment in the community may not have been met in the past. Therefore the aim of this study was to determine the prevalence of back, neck and shoulder problems that had restricted normal activity for more than one week during the last year and which health professionals (if any) patients had consulted about their symptoms. METHOD: A postal survey of 2400 adult patients selected at random from four general practices in Newcastle upon Tyne (600 from each practice). RESULTS: A total of 1546 questionnaires were returned, a 64% response rate. Overall, 40% of respondants reported having at least one back, neck and/or shoulder problem. Back problems were most common (30%), followed by those with neck (21%) and shoulder (20%) problems. Approximately one-third of those with problems consulted no one, a further third consulted a general practitioner and only one in six consulted a physiotherapist. CONCLUSIONS: There is a high prevalence of substantial back, neck and shoulder problems in the community and thus a wider provision of physiotherapy services within primary healthcare may be required to manage the considerable levels of potentially unmet need.

Adolescent↗

PubMed2006

Estimating transitions between symptom severity states over time in schizophrenia: a Bayesian meta-analytic approach.

We obtain the posterior predictive distribution of transition probabilities between symptom severity states over time for patients with schizophrenia by (i) employing a Bayesian meta-analysis of published clinical trials and observational studies to estimate the posterior distribution of parameters that guide changes in Positive and Negative Syndrome Scale (PANSS) scores over time and under the influence of various drugs and (ii) by propagating the variability from the posterior distributions of the parameters through a micro-simulation model that is formulated based on schizophrenia progression. Results show detailed differences among haloperidol, risperidone and olanzapine in controlling various levels of severities of positive, negative and joint symptoms over time. For example, risperidone seems best in controlling severe positive symptoms while olanzapine is the worst in that during the first quarter of drug treatment; however, olanzapine seems to be best in controlling severe negative symptoms across all four quarters of treatment while haloperidol is the worst in this regard. These details may further serve to better estimate quality of life of patients and aid in resource utilization decisions in treating schizophrenic patients. In addition, consistent estimation of uncertainty in the time-profile parameters also has important implications for the practice of cost-effectiveness analysis and for future resource allocation policies in schizophrenia treatment.

Antipsychotic Agents↗

PubMed2001

Improving estimates of caregiver time cost and family impact associated with birth defects.

BACKGROUND: Birth defects impose substantial costs on both families and society because of medical, developmental, and special education needs. Caring for children with birth defects also may influence caregiver time and impact the family. However, the economic cost of caregiver time and other impacts on the family has received far less attention than traditional healthcare costs. METHODS: This study reviews the literature on measuring caregiver time costs and family impact in an economic framework. The economic framework involves translating caregiver time or difficulties into appropriate units such as cost or quality adjusted life years (QALYs). RESULTS: Despite the potential important contribution of caregiver time costs to the total cost estimate of birth defects, few studies estimate caregiver time costs related specifically to birth defects. Only two studies provide estimates of these costs. Recent work has investigated the impact of chronic illness on caregivers in QALY terms, but birth defects have not been studied. Several issues need to be addressed in both the estimation of caregiver time costs and family impact to improve cost estimates. CONCLUSIONS: Improved estimates of caregiver time costs and impact on the family will assist policy makers in allocating resources for the prevention and treatment of birth defects. Future research should investigate the economic costs of caregiver time and family impact associated with caring for children with birth defects.

Caregivers↗

PubMed2002

Neural tube defect-specific infant mortality in the United States.

BACKGROUND: Significant resources have been devoted to decreasing the rate of neural tube defects (NTDs) in the United States. Both surveillance data and birth records have strengths and limitations for evaluating the outcomes of this resource allocation. Cause-specific infant mortality data can be used as one measure to support evaluation efforts. METHODS: Using period linked birth/infant death data from the National Center for Health Statistics (NCHS), a retrospective analysis was performed to assess the NTD-specific IMR at the national, state, and regional level. NTD-specific IMRs for the United States were calculated from 1996 to 1998; stratified rates by race/ethnicity, maternal age, age at death, and gestational age and birthweight by type of NTD for the total US population were based on three-year aggregates (1996-98); state and regional rates were based on four-year aggregates (1995-98). RESULTS: Annual US NTD-specific IMRs significantly decreased between 1996 and 1998. Black infants were significantly less likely to die from an NTD when compared to white infants, largely attributed to the high rate of NTD-specific deaths among white Hispanic infants. Infants born to women less than 20 years were more likely than infants born to women in other age groups to die from an NTD. Seventy-six percent of all NTD-specific deaths occurred in the first 23 hours of life. Seventy-four percent of NTD-specific infant deaths were low birthweight and 58 percent were preterm. The Midwest had the highest rate of NTD-specific infant deaths among US regions. CONCLUSION: Enhanced prevention efforts are needed to address the disparities in infant deaths due to NTDs between Hispanics and other populations, as well as women under 20 years. Decreases in NTD-specific IMRs may have been impacted by fortification of enriched grain products with folic acid since these efforts were optional beginning in 1996. While there are limitations in cause-specific IMRs, NTD-specific IMRs can be used as one measure to assess the impact of public health interventions aimed at reducing NTDs, respectful of the relatively small numbers.

Cause of Death↗

PubMed1998

Parasites influence social rank and morphology, but not mate choice, in female red junglefowl, Gallus gallus.

Parasites can profoundly affect host morphology and behaviour, but previous work has focused on the effects of parasites on males. In the present study, we assessed the effects of infection with the nematode Ascaridia galli on the morphology and behaviour, including mate choice, of female red junglefowl. Hens infected with A. galli had lower mass and smaller combs than unparasitized birds when sexually mature. Parasite status had a significant effect on social rank in all-female flocks, with high-ranking birds being less likely to be parasitized. Larger females had higher social rank, but comb size was unrelated to social status. Neither parasite status nor social rank had any effect on mate choice. These results differ from those found for male red junglefowl, and suggest that males and females may allocate resources differently to comb versus growth. The low cost of choice in the red junglefowl mating system may also contribute to the lack of an effect of parasites and social status on mate choice Copyright 1998 The Association for the Study of Animal Behaviour

Journal Article↗

PubMed1999

Prosody, linguistic demands, and auditory comprehension in aphasia.

Prosody plays a clear role in the auditory comprehension of narratives by aphasic listeners. Previous research, however, has pointed to questions regarding variables which increase task complexity (e.g., memory, reading level) and the influence of the severity of aphasia. This study examined the role of the severity of aphasia and linguistic complexity in narrative comprehension by aphasic listeners. Findings indicate that while all subject groups improved their auditory comprehension when emphasis was present, people with severe aphasia improved significantly more, but only in a low linguistic complexity condition. However, subjects had additional opportunity for improved performance in both low and high linguistic complexity conditions. These results pose additional questions about perceived task difficulty (and performance) and resource allocation strategies.

Adult↗

PubMed2001

Fictitious Academic Expertise and Processing Resources.

A previous study showed that pairs of students interacting in a second language produced more words when they were assigned a fictitious expert position in a specific competence dimension than when they were assigned a nonexpert position. It has also been shown that the usual level of expertise has an impact on the assigned fictitious expertise effect. The present study was designed to determine whether the processing capacity allotted to the current task could partly determine performance. A given position of expertise may demand a large or small attentional capacity. Two experiments were conducted using a dual-task paradigm. As expected, the different expertise positions led to different reaction times on the secondary task. The second experiment showed that the impact of assigning a position of expertise to students depends on their usual academic standing. This study supports the idea that in interactive situations, performance variations as a function of the expertise position can be partially explained by differences in the processing resources allocated to the task. Implications for teaching are discussed. Copyright 2001 Academic Press.

Journal Article↗

PubMed1996

Project management techniques applicable within the Department of Surgery.

The finite time span and the nonrepetitive nature of the project distinguish it from the routine activities characteristic of the management of a surgical department or division. Defined goals, specific (finite) resource allocation, and identifiable sequential phases also characterize the project. This paper reviews project management techniques that may be useful in the Department of Surgery.

General Surgery↗

PubMed2001

Finance modeling in the delivery of medical care in tertiary-care hospitals in the Department of Veterans Affairs.

BACKGROUND: In the mid-1990s, the Department of Veterans Affairs (DVA) implemented the Veterans Equitable Resource Allocation (VERA), a new financial model developed to attempt to better distribute the approximately $18 billion annual budget among roughly 170 Veterans Administration Medical Centers (VAMCs). VERA is based on a Health Maintenance Organization (HMO) model. VERA provides reimbursement to each of the 22 regional Veterans Integrated Service Networks (VISNs), and subsequent VISN distribution to individual VAMCs is based on an individual medical center's enrollment of unique social security numbers (uniques). In HMO vocabulary these are individual "covered lives." METHODS: Currently available demographic and staffing information regarding the DVA's 23 tertiary hospital systems (Category 7 hospitals) on the KLF database (DVA Austin Data Base) and published information on the DVA website were reviewed. The following was obtained: (1) staffing information-physician and nurse full-time employment equivalent (FTEE) staffing; (2) patient demographics and hospital workload-facility uniques (u), outpatient facility uniques, average daily census (ADC), discharges, and outpatient clinic visits. The following staffing ratios were calculated for both physician and nursing: FTEE/(u/1000), FTEE/(discharges/1000), FTEE/(clinic visits/1000), FTEE/ADC. For all categories the means +/- SD were calculated and correlation coefficients were calculated on pertinent pairings. RESULTS: Although categorized as similar tertiary care facilities, the 23 "Group 7" VA hospitals are anything but equivalent when reviewed using the VERA financing model with respect to physician staffing, nurse staffing, and facility uniques. Using VERA methodology, average physician FTEE and total nursing FTEE staffing/(u/1000) are 3.67 +/- 0.89 and 15.53 +/- 3.77, respectively. Correlation statistics of staffing versus unique SSNs demonstrated correlation coefficients of 0.46 and 0.59 with respect to physician and nurse staffing, respectively. On the other hand, when physician FTEE and nursing FTEE staffing were compared with VAMC workload parameters (total ADC, discharges, and outpatient visits), correlation coefficients were more consistent, ranging from 0.62 to 0.86. CONCLUSIONS: In the VERA model, the reward of a larger annual budget for an individual VAMC or the regional VISN is realized when staffing of VAMCs is minimized, overall provided medical services (especially costly tertiary services) are limited, and the number of covered lives is maximized. A VAMC staffing system that equates medical services delivered in a tertiary VAMC setting based on an HMO model like VERA (where the user population is skewed toward the sicker, older patient) shows decreased correlation when compared with VAMC workload model parameters.

Delivery of Health Care↗

PubMed1996

Evolutionary consequences of a trade-off between parental effort and mating effort.

I investigate the joint evolution of male and female strategies in a dioecious population where individuals can increase their access to mates by attacking or threatening rivals. In some species where individuals can increase their mating success in this way, both sexes allocate resources to parental effort. There may be a trade-off between parental effort and mating effort (for conflict over access to mates). If so, what factors must be included in the model for parental effort by both sexes to be evolutionarily stable? I analyse a simple game theoretic model that allows conflict over access to mates. Three versions of this model are analysed. In the simplest version, variation among individuals of each sex is allowed only in their total parental effort. The more elaborate versions of the model also allow variation in the parental investment per offspring. When this type of variation is allowed, a pair of male and female strategies can only be evolutionary stable if one sex alone contributes all parental effort. However, when non-heritable variation in the resources available to individuals is introduced (the third version of the model), parental effort by both sexes can be maintained.

Animals↗

PubMed1997

The evolutionary dynamics of selfish replicators: a two-level selection model.

The aim of the present paper is to study the evolutionary dynamics of selfish replicators in a constant genetic background. Selfish replicators are viewed as alleles at a single locus, having a pleiotropic effect. Infinitely many alleles are possible; they act on individual fitness and have various levels of ability to distort segregation. This results in a two-level process of selection, including inter-individual selection (effect on individual fitness) and intra-individual selection (ability to distort segregation). The model takes other parameters into account, such as dominance, inbreeding and inbreeding depression. The system can have two different behaviours. (1) In some cases, evolutionary cycles are possible. The cycles correspond to an alternation of phases with predominant inter-individual selection, corresponding to major-effect mutations, and phases with predominant intra-individual selection, corresponding to small-effect mutations. (2) For other values of the parameters, a synthetic fitness can be defined: this absolute allelic fitness is estimated as a function of one's fitness due to both inter-individual and intra-individual selection. During the course of evolution, the synthetic fitness increases. The optimisation of a synthetic fitness is the most general process. The optimised value is essentially homologous to the value optimised for resource allocation to male and female function in hermaphrodites (female function being homologous to the effect on individual fitness, and male function being homologous to distortion ability). The relative importance of both behaviours is discussed. It is argued that repeated sequences causing some human degenerative hereditary diseases may follow a two-step evolutionary process: a progressive increase in number of sequences accompanied by a decrease of the individual fitness would be followed by massive elimination of such sequences. But in general the optimisation of the synthetic fitness seems to be more likely.

Animals↗

PubMed2001

A conflict between two evolutionary levels in trees.

Due to the lack of germ line segregation in plants, it is possible to consider plant evolution (but not the evolution of most animals) as being composed of two evolutionary levels: 1. Intra-organism, in which the replicating unit is a part of the tree (e.g. a branch), reproduction is asexual, mutations are somatic, and selection operates only upon traits relevant to vegetative growth. 2. Inter-organism, in which the replicating unit is the whole tree, reproduction is sexual, and selection operates upon all the traits. In this work, a case of a conflict between these two levels is studied. The dynamics of a mutation, which is advantageous on the branch level but harmful for the whole tree, are discussed for a one-locus two-allele model. Several cases are considered: dominant, partially dominant, and haploid. Necessary and sufficient conditions for fixation of such a mutation are found. The model predicts that as the longevity of a tree species increases, the trees are expected to be more strongly shifted from their optimal growth-to-reproduction ratio towards growth, and resource allocation between branches and other tree parts is expected to be shifted in favor of the branches. Traditional approach, considering the second level only, is justified as a limit case for short longevity.

Biological Evolution↗