Ethics, justice, and commerce in organ replacement.
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Administrative Personnel↗
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Individual quality of life in patients undergoing hip replacement.
Quality of life (QoL) assessment is becoming increasingly important for measuring the impact of illnesses, diseases, and their treatment and for deciding priorities when allocating resources. We developed a novel method to measure QoL from the perspective of the individual patient. The schedule for the evaluation of individual quality of life (SEIQoL) was devised from the technique known as judgment analysis to measure patients' level of functioning in five self-nominated facets of life and the relative weight or importance attached to these areas. We applied this method, together with traditional measures of health status, in a prospective intervention study of 20 patients undergoing unilateral total hip-replacement surgery with six-month follow-up by comparison with matched, non-patient controls. Health status was significantly improved by hip replacement on the McMaster health index questionnaire (p less than 0.001) and the arthritis impact measurement scales (p less than 0.001). Individually measured QoL was significantly increased after surgery when measured by SEIQoL (p less than 0.02). The individual nature of QoL was reflected in the variety of life areas nominated as important by individual patients, the differences in relative weights attached to these areas, and the complex nature of the changes that occurred postoperatively. Our data not only highlight such individuality but also show that SEIQoL provides a means by which this can be assessed scientifically.
Adult↗
Physiological scoring systems and audit.
Scoring systems designed to rate the severity of an illness are being used for comparison of hospital units to identify different standards of care and to allocate resources. One such scoring system is the Acute Physiology and Chronic Health Evaluation (APACHE) system which is designed to assess the severity of illness of patients in intensive care units (ICUs). It is widely assumed that different ICUs can be compared by the ratio of actual mortality to that predicted by the APACHE score. However, we suggest that the use of physiological data that can be influenced by medical and nursing intervention should not be used for audit. For example, by good care a patient may be made less severely ill and, therefore, may have a lower actual mortality while, at the same time, accumulating only a low APACHE score with low predicted mortality. This patient could have, therefore, the same mortality ratio as a patient treated inappropriately, who may have a higher actual mortality and a high APACHE score with greater predicted mortality. Paradoxically, the very accuracy of these scoring systems for assessing the severity of illness precludes their use for comparison and audit.
Humans↗
Methods of cost-effectiveness analysis: areas of consensus and debate.
Methods of evaluating socioeconomic relationships have evolved over many years, and a number of specific approaches have been developed. Among the techniques available, cost-effectiveness analysis (CEA) has emerged as the most widely used and accepted method. Yet, despite considerable effort by the analytical community to refine this technique into one more useful for making health policy decisions, much debate and confusion still persist among analysts, readers, and policy-makers concerning methods standards and the overall usefulness of CEA in resource allocation decision making. Thus the purpose of this paper is to summarize, critically examine, and comment on existing recommended methods for socioeconomic evaluation of health care interventions. In particular, we examine an exhaustive set of component methods within the general area of cost-effectiveness and comment on areas of apparent consensus and debate. Our review reveals many areas of agreement and many yet to be resolved. Analysts generally agree on the components of the overall framework for an analysis; basic methodologic principles; the general treatment of costs; the principle of marginal analysis; the need for and general approach to discounting; the use of sensitivity analysis; the extent to which ethical issues can be incorporated; and the importance of choosing appropriate alternatives for comparison. The principal areas in which disagreement still persists are choice of study design, measurement and valuation of health outcomes including conversion of health outcomes to economic values, transformation of efficacy results into effectiveness outcomes, and the empirical measurement of costs.
Cost-Benefit Analysis↗
Recall and recognition memory deficits in depression.
The aim of the present study was to establish the nature of memory deficits of depressive subjects in word learning tests. A word learning test consisting of 1, 3 or 5 learning trials was used. We found that patients were characterized by inferior memory recall compared to controls when 5 learning trials were given. Patients performed significantly slower than controls on a recognition test but both patients and controls recognized the same number of words. This suggests that the memory deficits that are present in many depressive subjects may be restricted to impaired active retrieval from memory. A second experiment revealed that recognition memory and delayed recall as well as immediate recall were impaired in depressive patients after 1 learning trial. These short-comings vanished after 3 trials, except for immediate recall. These data suggest that not only retrieval but also encoding of information into memory may be impaired in depression, especially in the beginning of a task when demands on cognitive effort are high. The results are discussed in terms of resource allocation and demands on effort that may change in the course of a task.
Adult↗
Leximin population ethics.
This paper concerns the ethical issues that arise when policy decisions have to be taken that affect population size and characteristics. Such policies include social security systems, intertemporal resource allocation decisions, and policies designed to influence fertility rates. The authors provide characterizations of Leximin principles for social evaluation in an intertemporal framework, so that they can be used to compare social alternatives with different population sizes. "The main axioms used in our characterizations are Hammond Equity together with Independence of the Utilities of the Dead (a plausible intertemporal consistency requirement) for the Critical-Level Leximin principles, and Positional Leximin Consistency (an axiom that allows non-constant critical levels) for the Positional-Extension Leximin principle. The performance of these principles is compared in the pure population problem and we argue that the Critical-Level Leximin principles are ethically more attractive than Positional-Extension Leximin."
Demography↗
Cortisone extends life span in the rotifer Asplanchna brightwelli.
Cortisone at 100 and 200 microM concentrations produced a significant increase in both life span and reproduction in the rotifer Asplanchna brightwelli. Two possible mechanisms are discussed to explain these results: (1) cortisone stabilization of lysosomal membranes, or (2) recognition of cortisone as a hormone capable of altering resource allocation by the rotifers.
Animals↗
Coronary arterial surgery in the elderly: its effect in the relief of angina.
Financial and other constraints, such as operative risk, may prevent older patients being considered for coronary arterial bypass grafting. Grafting was performed in 315 elderly patients (244 males, 71 females, age 65-79, mean 69 years) between 1981-1986. All patients had limiting angina, 38% had rest pain, 90% were housebound and 80% had triple-vessel disease. Impairment of left ventricular function was absent in 46%, mild in 20%, moderate in 23% and severe in 10% of patients. Grafts (saphenous vein or internal mammary artery) were inserted into 3 vessels (52%), 4 vessels (42%), 5 vessels (6%), 6 vessels (0.5%). Death during surgery occurred in 1.6% and a further 3.5% of patients died later during the same admission (70% of deaths were among the 33% with preoperative moderate or severe left ventricular impairment). Surgical complications included myocardial infarction (8%), cerebrovascular accident (1%), transient cerebral vascular ischaemia (5%), chest infection (10%) and wound infection (4%). Median stay on the intensive care unit was 1 day and median total hospital stay 12 days. 299 patients therefore survived to leave hospital and follow-up data are available for 217 (72%) of these. 96% were subjectively improved by surgery, 88% being free of angina on no antianginal drugs a median of 72 weeks (range 8-307) and a further 8% not limited by angina on medical therapy a median of 85 weeks (range 9-302) after surgery. We conclude that coronary arterial surgery is an effective treatment for angina in the elderly. This will have consequences for future resource allocation if the elderly are not to be denied effective therapy because of financial rather than clinical restraints.
Aged↗
Technological diffusion in primary health care.
The paper contains a theoretical and empirical analysis of the driving forces behind the diffusion of dry chemical laboratory equipment in Norwegian primary health care. The empirical analysis is embedded in a theoretical model of a dynamic investment problem focusing on heterogeneity in the potential adopters' profit functions. The empirical analysis indicates that most adopters are too late in adopting the new technology. A logit analysis of the diffusion process lends some support to the notion that profit function heterogeneity influences the diffusion process. An offspin of the empirical analysis is information on the reimbursement system, indicating that this system does not promote efficient resource allocation in the sector.
Autoanalysis↗
Influence of a sampling review process for radiation oncology quality assurance in cooperative group clinical trials--results of the Radiation Therapy Oncology Group (RTOG) analysis.
The Radiation Therapy Oncology Group (RTOG) designed a random sampling process and observed its influence upon radiotherapy review mechanisms in cooperative group clinical trials. The method of sampling cases for review was modeled from sampling techniques commonly used in pharmaceutical quality assurance programs, and applied to the initial (on-study) review of protocol cases. 'In control' (IC) status is defined for a given facility as the ability to meet minimum compliance standards. Upon achieving IC status, activation of the sampling process was linked to the rate of continued patient accrual for each participating institution in a given protocol. The sampling design specified that > or = 30% cases not in compliance would be detected with 80% power. A total of 458 cases was analyzed for initial review findings in four RTOG Phase III protocols. Initial review findings were compared with retrospective (final) review results. Of the 458 cases analyzed, 370 underwent initial review at on-study, while 88 did not require review as they were enrolled from institutions that had demonstrated protocol compliance. In the group that had both initial and final review, 345/370 (93%) were found to have followed the protocol or had a minor variation. Of the exempted cases, 79/88 (90%) were found to be per protocol or a minor variant. The sampling process proved itself to be cost-effective and resulted in a noticeable reduction in the workload, thus providing an improved approach to resource allocation for the group. Continued evaluation of the sampling mechanism is appropriate as study designs and participants vary over time, and as more data become available to study.(ABSTRACT TRUNCATED AT 250 WORDS)
Clinical Protocols↗
Drug consumption in elderly diabetics.
The drug use in 228 persons with diabetes was studied and compared with that of sex- and age-matched non-diabetic controls--all of whom were found by the screening of a well-defined Danish population aged 60-74 years. Ninety per cent of the diabetics had non-insulin-dependent diabetes mellitus (NIDDM), as evaluated by a glucagon-C-peptide test. Information on daily use of prescribed and non-prescribed drugs was obtained by questionnaires and interviews. More than 80% of the diabetics used drugs daily, compared to 55% of control subjects (P less than 0.00001). Among subjects using drugs diabetics, on average, used 70% more defined daily doses (DDD) than controls, even when antidiabetics were excluded. There was no difference in the number of drug users among subgroups of diabetics when divided according to antidiabetic treatment but tablet-treated diabetics, on average, used 20% fewer DDD than other diabetics. Cardiovascular drugs were the most commonly used drugs. Diabetics in all antidiabetic treatment groups used significantly more cardiovascular drugs than non-diabetics. Diabetics treated with oral antidiabetics used fewer cardiovascular drugs than insulin- and diet-treated diabetics. The estimated cost of drug therapy was more than 2.5 times higher for diabetics than for the control group. Our results reflect the increased morbidity among elderly diabetics and emphasise, together with other aspects of costs of diabetes in the elderly, the need for allocating resources for the prevention of NIDDM instead of the treatment of its complications.
Aged↗
Health care financing in the Netherlands: recent changes and future options.
Following a short outline of the structure of the Dutch health care system and the regulatory activities of the government, budgeting in health care is being considered at three levels: the national level, the level of the health care institution and the intermediate level of the region. The authors foresee that regional budgeting and regional policy-making will become more important. Instead of a nation-wide introduction of the Health Services Act, which means more government interference at regional and local levels in health care, the authors believe that a re-orientation on market-principles as the dominating mechanism in resource allocation in health care will take place in the coming years. This will coincide with strengthening the position of sickness funds and private insurers at the cost of that of provincial and local government.
Data Collection↗
Assessing the economic burden of injuries due to accidents: methodological problems illustrated with some examples from the literature.
This paper provides a survey of methodological problems encountered in an assessment of the economic consequences of accidents in The Netherlands. A sound epidemiological basis for such calculations appears to be lacking due to inadequate data-registration systems. We also discuss some studies of the economic costs of injuries due to accidents for other countries, which have used either a prevalence or an incidence-based approach. It is highlighted that they may be helpful in indicating the relative economic burden posed on society but that they cannot guide priority setting in health care resource allocation. Economic evaluation studies using incidence-based scenario comparisons may be more promising in that respect.
Accidents↗
Trends in health services management.
This paper describes how the NHS in the United Kingdom needs to continue to adapt and evolve in response to six major pressures, and how the corresponding challenge facing managers in the NHS is how to cope, adapt and tackle those pressures. The foundation was laid in 1984 with the introduction of general management from central government down to the sub-units of the nine District Health Authorities in Wales. This signalled a change in the service from one merely administered to one which was actively managed. The NHS manager must now concentrate on a number of fronts, notably planning, performance objectives, policy management, resource allocation and positive management of change. The Corporate Management Programme for Wales published in 1988 reinforces fundamental management principles and describes an agenda of management initiatives and objectives for the NHS in Wales over the next five years. The Programme has initiated the process of Corporate Planning. The future trend in health services management is interwoven with the programme of reform of the NHS introduced by the Government's White Paper 'Working for Patients' published in 1989. Initiatives introduced in Wales which will assist this programme of reform are described.
Administrative Personnel↗
The development of minimally invasive therapy in the United Kingdom.
The diffusion of minimally invasive therapy (MIT) must be understood against the background of sweeping changes in the organisation and funding of the National Health Service (NHS) in the UK. The separation of purchasers from providers of health care makes national policy, in theory, less important, as local developments are supposed to drive the process of needs assessment and resource allocation. Within this climate new technologies increasingly have to prove their cost-effectiveness. Yet the country case study illustrates that such studies lack established methodologies and wide application. One of the key barriers to diffusion lies within the profession itself, where resistance to paradigmatic change is the strongest force against innovation. The partnership between innovative clinicians and forward-looking managers is important if diffusion of new procedures is to be secured. The discussion of the 10 examples will highlight some of these important issues.
Angioplasty, Balloon, Coronary↗
Assessment of health producing measures across different sectors.
To date, economic evaluation of health producing measures has concentrated on health care treatments and technologies. However, it is increasingly being recognized that many health promoting measures are in other sectors, such as education, safety programmes, income maintenance and improvements to the physical environment. This paper examines the principles of assessing health promoting measures across different sectors and reviews current practice. Such assessments pose methodological challenges not often encountered in health care evaluations, in framing the evaluation, in identifying, measuring and valuing costs and benefits, and in interpreting results. It is concluded that intersectoral economic evaluation is unlikely to provide a complete technical solution to the problem of allocating resources within and between sectors of the economy, but that the application of an economic way of thinking could yield benefits. Five proposals are made for taking matters forward. These include undertaking more pilot studies, insisting on a minimum data set to justify spending plans and increasing the incentives for intersectoral collaboration.
Canada↗
Cost-effectiveness league tables: think of the fans.
In a recent issue of Health Policy, Birch and Gafni argued against the use of cost-effectiveness league tables in health care decision making. They argued that league tables should be returned to where they are best used and understood--the sports pages. Recently the debate about the presentation and interpretation of cost-effectiveness data has been given an additional impetus in the UK through the publication, by the Department of Health, of the Register of Cost-Effectiveness Studies (RCES). During the production of the RCES, it became apparent that there were similarities between the decision makers' thirst for economic data and the sports fans' thirst for information about their team. In this paper we review the pros and cons of using published cost-effectiveness data in decision making, compared with the local team approach suggested by Birch and Gafni. We conclude that there are advantages from using published data, providing these are produced according to standardized methods and interpreted intelligently. Most importantly, cost-effectiveness data, whether published or generated locally, are unlikely to give decision makers a technical solution to the resource allocation problem. Rather, they should be viewed as a stimulus for local discussion and debate.
Cost-Benefit Analysis↗
Health care expenditures for the elderly and reforms in the health care system in Japan.
In recent times, significant reforms have been instituted in Japan's health care system, such as the introduction of hospital categorization and the clarification of hospital roles, together with the establishment of geriatric health care facilities, and the reform of the pharmaceutical distribution and pricing system. These reforms are expected to improve the efficiency and quality of the health care system in Japan and to provide better care for the aging society. The changes will also eventually affect health care costs and patterns of services. This paper describes Japan's health care system, including the recent reforms, and then examines the costs and patterns of health care services for the elderly in the light of the recent changes in the system. While more resource allocation is necessary for training of workers for nursing, rehabilitation and care-giving, drugs should be more cost-effective and fit for use at home and in non-medically oriented institutions. Health care providers, health care industries and the government need further to properly respond to the changes in demography, patterns of diseases and disabilities and patients' wishes for better quality of life.
Aged↗