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PubMed2002

Tryptophan depletion effects on EEG and MEG responses suggest serotonergic modulation of auditory involuntary attention in humans.

Involuntary attention shifting, i.e., detecting and orienting to unexpected stimulus changes, may be altered at low brain serotonin (5-hydroxytryptamine; 5-HT) levels. This was studied in 13 healthy subjects (21-30 years old; 6 females) by using a dietary challenge, acute tryptophan depletion (ATD), which decreases 5-HT synthesis in the brain. Five hours after ingestion of either ATD or control mixture (randomized, double-blinded, crossover design), brain responses indexing involuntary attention were measured with simultaneous 64-channel electroencephalography (EEG) and 122-channel magnetoencephalography (MEG). During the measurement, the subjects were instructed to discriminate equiprobable 200- and 400-ms tones by pressing one of two buttons rapidly. Occasionally, the frequency of the tones changed (10% increase/decrease), causing involuntary attention shifting. ATD significantly lowered plasma tryptophan concentrations (total tryptophan decreased by 75%, free tryptophan decreased by 35%). As compared to the control condition, ATD reduced the amplitude of the deviant-tone N2 wave, including the overlapping mismatch negativity (MMN) and N2b subcomponents, which are suggested to reflect change detection in the brain. The EEG results were accompanied by a significant increase in the peak latency of the magnetic counterpart of MMN. However, no ATD effects were observed in P3 to task-irrelevant frequency change. Reaction time (RT) to deviants per se was not significantly affected, but RT in trials succeeding the deviant-frequency tones was increased by ATD, which suggested impaired reorienting to the task-relevant activity. In conclusion, the results suggest that decreased level of central 5-HT function after ATD may decrease involuntary attention shifting to task-irrelevant sound changes and thus modulate resource allocation to the task-relevant activity.

Acoustic Stimulation↗

PubMed1989

Inequity in health. A case study.

This article presents a particular case of inequity in health, that of two types of Israeli urban settlement: development towns and veteran towns. Inequity in health is demonstrated by the varying levels of resources allocated to each type of community, by the differences in health-care utilization (process), and by the diversity of external factors affecting the two categories of towns. Despite the existence of almost universal health insurance coverage in Israel, it is shown that inhabitants of less privileged development towns are more prone to inequitable health outcomes with respect to the wealthier populations living in veteran towns. This case illustrates an integrated approach to inequity in health, including the health-care system structure, utilization patterns, and the socio-demographic-economic background of different strata.

Adult↗

PubMed1982

The Kentucky elderly need assessment: concurrent validity of different measures of unmet need.

The purpose was to examine the concurrent criterion-based validity of different measures used in a statewide in-home need assessment survey of a representative sample of 570 older persons. Need was measured and defined in four different ways in six problem areas. The criterion measure was a life satisfaction scale. The set of four need measures yielded a significant multiple R, indicating that the set would generally be related to life satisfaction in older persons. Individually, three of the four need measures made significant contributions. The set of six problem areas also yielded a significant multiple R, with four (Mental Health, Health, Income, Nutrition) making significant individual contributions. Implications for need assessment measurement included: that problem-focused measures are strongly and generally related to need satisfaction, whereas service-focused measures have problems; that both evaluative and descriptive measures appear to be related to need satisfaction; and the clear value of a multineed conception for measurement and for application to program planning and resource allocation. Suggestions for improvement in measures were made and cross-validation called for.

Aged↗

PubMed1975

The effect on future physician requirements of an HMO policy after national health insurance.

The questions examined in this paper are: What effect will the Health Maintenance Organization (HMO) have on future physician manpower? What is the likelihood of there being a substantial movement of medical practice to the HMO form? Answers indicate that national health insurance will produce a more regulated and constrained resource allocated to health services and, hence, the demonstrated efficiencies of the HMO form will have strong appeal. The reduced physician manpower use of this type of organization is described. The result of these interactions will probably be a substantial reduction in the ratio of physicians needed 20 years from now.

Allied Health Personnel↗

PubMed1996

An attempt towards differentiating attentional deficits in traumatic brain injury.

Attentional deficits in patients suffering traumatic brain injury (TBI) can occur with minor to severe impact to the brain. Based on reviews of both the cognitive and neurobehavioral literature, the following three concepts of attention are addressed: (a) arousal/alertness, (b) selective attention, and (c) energetic aspects of attention, which include such components as effort, resource allocation, and speed of processing. Within each concept, definitions are proposed, the underlying brain mechanisms are identified, and the specific deficits associated with TBI are explored. This review combines theoretical perspectives and clinical findings with the objective of leading toward a diagnostic differentiation that in turn will benefit treatment planning.

Arousal↗

PubMed1989

Urban-rural migration: uncertainty and the effect of a change in the minimum wage.

"This paper extends the neoclassical, Harris-Todaro model of urban-rural migration to the case of production uncertainty in the agricultural sector. A unique feature of the Harris-Todaro model is an exogenously determined minimum wage in the urban sector that exceeds the rural wage. Migration occurs until the rural wage equals the expected urban wage ('expected' due to employment uncertainty). The effects of a change in the minimum wage upon regional outputs, resource allocation, factor rewards, expected profits, and expected national income are explored, and the influence of production uncertainty upon the obtained results are delineated." The geographical focus is on developing countries.

Agriculture↗

PubMed1995

Effects of oxazepam on event-related brain potentials, EEG frequency bands, and vigilance performance.

Eighteen males performed two vigilance tasks with static and dynamic stimuli under the influence of oxazepam (20 and 40 mg) in a placebo-controlled, double blind, crossover design. Oxazepam dose-dependently impaired overall level of performance and aggravated the decrement with time in measures of accuracy and sensitivity relative to placebo. The drug reduced the amplitudes of the P1, N1, P2N2, and P3 (dose-dependently) waves of event-related potentials (ERPs). Oxazepam aggravated the linear decline with time of the P3 amplitude only. Oxazepam impaired accuracy was related to deterioration of central processing involved in stimulus discrimination (P2N2). Impairment of response-related performance measures (RT and RI) was associated with processing manifest in the P1, N1, and P3 waves. Oxazepam effects on the amplitudes of N1 and P3 correlated with drug effects on power in alpha 1 (8-10 Hz). Drug effects on overall performance and alpha were also related; the drug effect on response speed correlated only with the drug effect on beta 1 (12.5-21 Hz). Effects of time-on-task on performance and EEG were unrelated, but oxazepam induced performance declines with time may have been caused by declines in resource allocation, as manifest in the amplitude of P3. Time effects on EEG power bands and ERP amplitudes were not significantly related to the time course of oxazepam activity. A curious dissociation emerged: both oxazepam and time-on-task impaired performance, but the drug induced a decrease of theta and alpha 1 power, whereas time-on-task increased power. Various processes play a role in performance decrements with time, and various aspects of processing may be involved in signal-detection measures which makes terms such as sensitivity quite meaningless. So-called computational processing was indistinguishable from energetic processes, which questions the validity of the distinction between these two domains. Explanations of EEG activity in terms of a unidimensional theory of arousal are untenable.

Adult↗

PubMed1996

New Zealand health care financing 'reforms' perceived ideological context.

Health sector financing reforms that have been ongoing over the last decade in most developed countries are rooted in philosophical terms in the ideology of economic rationalism. The ideology suggests that it is possible to artificially create markets for activities in contexts where markets do not develop naturally, and that the creation of these artificial markets leads to resource allocations that are both more efficient and more equitable than historical arrangements. The application of the ideology to New Zealand's health sector has generated some benefit--for example, a more rational approach to influencing the decisions of self-interest health care providers; but it has also generated some costs--for example, on ideological grounds it has brought into question the non-market rationales for maintaining a national health service system.

Financing, Government↗

PubMed2000

Predicting service utilization with the Child and Adolescent Functional Assessment Scale in a sample of youths with serious emotional disturbance served by center for mental health services-funded demonstrations.

This study investigated level of restrictiveness of living arrangements and number of days in out-of-family care at six months postintake, based on the Child and Adolescent Functional Assessment Scale (CAFAS), the Child Behavior Checklist (CBCL), gender, age, and level of family income at intake. It was composed of youths who met the criteria for serious emotional disturbance (SED) and were for the most part living in families that are described as socioeconomically disadvantaged. A multinomial logit model was used in the analysis of level of restrictiveness of living arrangements, and an ordinary least squares (OLS) regression model was conducted on number of days in out-of-family care. The CAFAS score at intake was found to be a significant predictor of service utilization between intake and six months and was a more consistent predictor than the CBCL. Results suggest that the CAFAS can be used to match service needs with resource allocation and to monitor performance-based outcome indicators.

Adolescent↗

PubMed1992

Alcoholism treatment, severity of alcohol-related medical complications, and health services utilization.

In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment.

Adult↗

PubMed1994

Supporting primary care medical education.

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible.

Adult↗

PubMedDate not supplied

Medical evaluation of child abuse.

Child abuse is a world-wide problem and has existed in all societies and cultures in various forms since ancient times. Intrafamilial physical and sexual abuse is well recognized in United States and other western countries. In countries like India there is a general lack of sensitivity to the issue among professionals and the lay public alike. The pressing issues of poverty, malnutrition, and infectious diseases take priority on resource allocation. Although some of the methods of child rearing and discipline may be culturally sanctioned and inherent, it does not necessarily mean they are harmless. In this paper the authors present clinical signs and symptoms of physical and sexual abuse which occur in the intrafamilial context and are of direct relevance to the medical practitioner.

Child↗

PubMed1993

Are deprivation indicators a proxy for morbidity? A comparison of the prevalence of arthritis, depression, dyspepsia, obesity and respiratory symptoms with unemployment rates and Jarman scores.

The aim of the study was to examine the relationship between specific areas of morbidity measured using validated survey questions and deprivation indicators to see if the latter could act as a proxy in health needs assessment, health service planning and resource allocation in a typical health authority. A postal questionnaire was used to provide information about arthritis, depression, dyspepsia, obesity and respiratory symptoms in a simple random sample from the study population. The questions were from survey instruments that have been widely used to derive information about these conditions. The relationships between the prevalence of these specific areas of morbidity and both unemployment and the Jarman Underprivileged Areas Score were explored. Spearman's rank correlation coefficients were calculated and compared for each combination of measures. The study population was a random sample of the residents of each of the 22 electoral wards in Rotherham Health Authority. Responses were obtained from 82 per cent of the 5000 sampled. Although all morbidity measures showed positive correlations with both Jarman score and unemployment, some, notably those relating to respiratory disease and depression, were much more strongly correlated than others, such as obesity. There was no difference between unemployment and Jarman score in respect of the magnitude of the correlation coefficients. In conclusion, for some, but not all, conditions socio-economic measures are a good proxy for morbidity. Unemployment is just as useful a proxy as the Jarman score.

Arthritis↗

PubMed1997

Optimization of a low-cost truly preemptive multitasking PC diagnostic workstation.

The Windows 95/NT operating systems (Microsoft Corp, Redmond, WA) currently provide the only low-cost truly preemptive multitasking environment and as such become an attractive diagnostic workstation platform. The purpose of this project is to test and optimize display station graphical user interface (GUI) actions previously designed on the pseudomultitasking Macintosh (Apple Computer, Cupertino, CA) platform, and image data transmission using time slicing/ dynamic prioritization assignment capabilities of the new Windows platform. A diagnostic workstation in the clinical environment must process two categories of events: user interaction with the GUI through keyboard/mouse input, and transmission of incoming data files. These processes contend for central processing units (CPU) time resulting in GUI "lockout" during image transmission or delay in transmission until GUI "quiet time." WinSockets and the Transmission Control Protocol/Internet Protocal (TCP/IP) communication protocol software (Microsoft) are implemented using dynamic priority timeslicing to ensure that GUI delays at the time of Digital Imaging and Communications in Medicine (DICOM) file transfer do not exceed 1/10 second. Assignment of thread priority does not translate into an absolute fixed percentage of CPU time. Therefore, the relationship between dynamic priority assignment by the processor, and the GUI and communication application threads will be more fully investigated to optimize CPU resource allocation. These issues will be tested using 10 MB/sec Ethernet and 100 MB/sec fast and wide Ethernet transmission. Preliminary results of typical clinical files (10 to 30 MB) over Ethernet show no visually perceptible interruption of the GUI, suggesting that the new Windows PC platform may be a viable diagnostic workstation option.

Algorithms↗

PubMed2004

Evaluation of proposals of Belgian Social Security Institute for reimbursement of bone densitometry tests. Toward a cost-effective strategy for osteoporosis screening?

BACKGROUND AND AIMS: The Belgian Social Security Institute (hereafter INAMI) proposes a list of conditions to be considered as a prerequisite for reimbursement of Bone Mineral Density (BMD) measurements. The aim of this paper was to evaluate the diagnostic accuracy of the proposed criteria for identifying osteoporosis, and to gauge how useful they are for more rational application of densitometry tests. METHODS: 3748 Caucasian women aged at least 50 years old were recruited consecutively from an outpatient university center, from the database of which all relevant data corresponding to the INAMI list of clinical factors, as well as patients' age, weight and height, were collected. BMD measurements using dual X-ray absorptiometry were reported at the spine and hip regions. Diagnostic accuracy was evaluated through measures of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Additionally, from ROC analysis, benchmark values for age and body mass index were identified and then, used alone and in combination with the INAMI test, were applied to define various screening strategies. For each of them, associated costs per osteoporotic patient detected were estimated. Cost estimates refer only to the costs associated with the densitometric procedure from the perspective of the reimbursement health authorities. RESULTS: Applying INAMI criteria for detecting osteoporosis at any of the considered sites yielded sensitivity of 68.9%, specificity of 50.7%, PPV of 42.9% and NPV of 57.3%. Comparison of incremental costs per patient of the different strategies revealed that, with 67.1 Euros, the option of opening BMD coverage to women on the basis of the INAMI conditions would be more cost-effective than mass screening (90.1 Euros) or applying the age criterion alone (70.2 Euros). However, the BMI condition seems to act as a better indicator of risk than the INAMI criteria in those meeting the age condition (35.4 Euros). CONCLUSIONS: The accuracy of the INAMI proposal turns out to be quite unsatisfactory, and did not adequately cover the population at risk of osteoporosis. From a resource allocation perspective, the best strategy by far would be to recommend using concomitantly INAMI, age and BMI-selective criteria. Some adaptations could enhance the usefulness of the INAMI proposals as a selective approach for BMD referral and reimbursement.

Absorptiometry, Photon↗

PubMed2001

[Concept of indicators: central element of quality management].

BACKGROUND: Explicit data on the quality of health care in addition to economic data represent major instruments of internal as well as external controlling and resource allocation. INDICATORS: Indicators are selected parameters, which are able to monitor health care in regard to particular features and (adverse) events. They have to be evaluated for their feasibility, reliability and validity. Indicators are expected to play a central role in external quality assurance in Germany, and are a key issue in recent health legislation. Combinations of indicators lead to indicator systems, which have to undergo validation as well. The "Kooperation für Transparenz und Qualität" (KTQ) which is now extensively used in Germany, is an example for an indicator-based accreditation system. PERSPECTIVES: Issues of further discussion are loss of validity of indicators due to awareness and alteration of documentation habits, public disclosure, and the evaluation of indicators by means of evidence-based medicine.

Germany↗

PubMed2004

[Evidence-based intensive care medicine. Practice, use and significance].

The process of evidence-based medicine incorporates structured clinical problem solving aimed at providing an optimal, patient-centred therapeutic approach. Evidence-based medicine is supported by justified therapeutic principles rather than physicians' intuition only. Few of the published articles allow firm conclusions for a rational patient approach. The methodological quality of at least some of these articles is insufficient to guide rational therapy. Thus, critical appraisal of the literature seems mandatory. The following article highlights the process of evidence-based medicine and its implementation in daily clinical practice. Besides the careful analysis of source data, evidence-based medicine warrants the final evaluation of outcomes for process improvement. This can be obtained utilising surrogate parameters, such as organ failure, resource allocation, or quality of life, or crude mortality of the patients. The integration of personal know-how together with sufficient knowledge and critical appraisal of the current literature may finally lead to improved outcomes.

Catheterization, Swan-Ganz↗

PubMed2004

[Procedure optimization in hospital management].

Starting January 1st 2004 the German diagnosis-related group (DRG) system was established for in-patient cases. Consequently, the detection and realization of cost-saving potentials are becoming more and more important. For a successful future, efficient allocation of resources is essential. Economically, anaesthesia-related time delays during perioperative work-flow should be minimized. Since numerous entities contribute to perioperative care, it is extremely complex to analyze and optimize this process flow. In this publication single steps leading to an optimized perioperative process flow will be presented: documentation of predefined time points, calculation of relevant time intervals and analysis of key numbers for complex settings. Single steps of the given process analysis will be demonstrated using data from surgical patients at the University Hospital Schleswig-Holstein, Campus Kiel. The attached data collection sheets can be used by interested hospital departments and are meant to serve as a template for further process analyses. Based on the shown analysis, an example will be given to develop an optimized work-flow as a standard operating procedure (SOP). The implementation of the SOP module in an interdisciplinary clinical pathway (CP), which defines efficient medical care from admission to discharge, is mainly responsible for decreased process costs but increased quality of care.

Anesthesia Department, Hospital↗