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1.
BMC Health Serv Res ; 21(1): 82, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33482807

RESUMO

BACKGROUND: Given projected shortages of critical care capacity in public hospitals during the COVID-19 pandemic, the South African government embarked on an initiative to purchase this capacity from private hospitals. In order to inform purchasing decisions, we assessed the cost-effectiveness of intensive care management for admitted COVID-19 patients across the public and private health systems in South Africa. METHODS: Using a modelling framework and health system perspective, costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW + ICU) versus (2) general ward only (GW) were assessed. Disability adjusted life years (DALYs) were evaluated and the cost per admission in public and private sectors was determined. The model made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated with severity of disease, and the unit cost per general ward day and per ICU day in public and private hospitals. Unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing difference in costs and health outcomes of the two management strategies - was compared to a cost-effectiveness threshold to determine the value for money of expansion in ICU services during COVID-19 surges. RESULTS: A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in GW as opposed to ZAR 103,030 in GW + ICU. DALYs were 1.48 and 1.10 in GW versus GW + ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER of ZAR 73,091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38,465. CONCLUSIONS: Results indicated that purchasing ICU capacity from the private sector during COVID-19 surges may not be a cost-effective investment. The 'real time', rapid, pragmatic, and transparent nature of this analysis demonstrates an approach for evidence generation for decision making relating to the COVID-19 pandemic response and South Africa's wider priority setting agenda.


Assuntos
COVID-19/economia , Análise Custo-Benefício , Cuidados Críticos , Humanos , Quartos de Pacientes , Anos de Vida Ajustados por Qualidade de Vida , SARS-CoV-2 , África do Sul
2.
S Afr Med J ; 110(2): 88-91, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-32657675

RESUMO

The Competition Commission's Health Market Inquiry (HMI) is the most systematic and comprehensive investigation carried out into the South African private health sector. The recommendations as set out in the HMI Final Report merit extensive discussion and debate, as they could - if implemented - have far-reaching consequences for the future of the healthcare system. The objective of this article is to contribute to this discussion by providing an overview of the key findings and recommendations of the HMI and highlighting the resultant key imperatives at this critical juncture of policy development.


Assuntos
Atenção à Saúde/organização & administração , Competição Econômica , Setor de Assistência à Saúde/organização & administração , Setor Privado/organização & administração , Atenção à Saúde/economia , Setor de Assistência à Saúde/economia , Política de Saúde , Humanos , Setor Privado/economia , África do Sul
3.
S Afr Med J ; 111(1): 20-22, 2020 11 24.
Artigo em Inglês | MEDLINE | ID: mdl-33404000

RESUMO

Healthcare demands are rising globally, and regardless of the approach to financing and delivering healthcare services, no country can meet all the healthcare demands of its population. The demand-supply gap for healthcare services in South Africa (SA) is large, particularly for the public sector. The objectives of this article are to examine some of the underlying factors contributing to this gap, and how the COVID- 19 pandemic is likely to impact on them, and to describe why SA needs to adopt an explicit and equity-informed approach to healthcare priority-setting to assist in managing the gap.


Assuntos
Política de Saúde , Prioridades em Saúde , Necessidades e Demandas de Serviços de Saúde , Serviços de Saúde/provisão & distribuição , COVID-19 , Alocação de Recursos para a Atenção à Saúde , Reforma dos Serviços de Saúde , Equidade em Saúde , Humanos , Programas Nacionais de Saúde , SARS-CoV-2 , África do Sul
4.
S Afr Med J ; 108(1): 23-27, 2017 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-29262974

RESUMO

BACKGROUND: South Africa (SA) is in the process of implementing National Health Insurance (NHI), which will require co-ordination of health provision across sectors and levels of care. Clinical practice guidelines (CPGs) are tools for standardising and implementing care, and are intended to influence clinical decision-making with consequences for patient outcomes, health system costs and resource use. Under NHI, CPGs will be used to guide the provision of healthcare for South Africans. It is therefore important to explore the current landscape of CPG developers and development. OBJECTIVE: To identify and describe all CPGs available in the public domain produced by SA developers for the SA context. METHODS: We conducted a cross-sectional evaluation using a two-part search process: an iterative, electronic search of grey literature and relevant websites (161 websites searched), and a systematic search for peer-reviewed literature (PubMed) after publication year 2000. CPGs were identified, and data were extracted and categorised by two independent reviewers. Any discrepancies were referred to a third reviewer. Data extracted included a description of the developer, condition, and reporting of items associated with CPG quality. RESULTS: A search conducted in May 2017 identified 285 CPGs published after January 2000. Of those, 171 had been developed in the past 5 years. Developers included the national and provincial departments of health (DoH), professional societies and associations, ad hoc collaborations of clinicians, and the Council for Medical Schemes. Topics varied by developer; DoH CPGs focused on high-burden conditions (HIV/AIDS, tuberculosis and malaria), and other developers focused on non-communicable diseases. A conflict of interest statement was included in 23% of CPGs developed by societies or clinicians, compared with 4% of DoH CPGs. CONCLUSION: Accessing CPGs was challenging and required extensive searching. SA has many contributors to CPG development from the public and private sectors and across disciplines, but there is no formal co-ordination or prioritisation of topics for CPG development. Different versions of the CPGs were identified and key quality items were poorly reported, potentially affecting the usability and credibility of those available. There was substantial variation in CPG comprehensiveness and methodological approach. Establishing a national CPG co-ordinating unit responsible for developing standards for CPG development along with clinical quality standards, and supporting high-quality CPG development, is one essential step for moving forward with NHI.


Assuntos
Atenção à Saúde , Guias de Prática Clínica como Assunto/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Tomada de Decisão Clínica , Estudos Transversais , Atenção à Saúde/organização & administração , Atenção à Saúde/normas , Humanos , Avaliação das Necessidades , Desenvolvimento de Programas , África do Sul
5.
S Afr Med J ; 107(10): 832-835, 2017 09 22.
Artigo em Inglês | MEDLINE | ID: mdl-29022523

RESUMO

Improving access to basic surgical interventions has great potential to improve the length and quality of life of many people in low- and middle-income countries (LMICs). However, research has shown that current access to surgical interventions is limited, and initiatives such as the Lancet Commission on Global Surgery 2030 advocate for improved access to basic surgical interventions for all. As the needs, health system context and available budgets in each country will be different, a critical component of effective local scale-up of surgical interventions will be to use tools and processes of health technology assessment (HTA). HTA has traditionally been used in high-income countries to make decisions about which medicines and devices should be available in a health system, but its central concepts, such as assessing clinical effectiveness, cost-effectiveness and feasibility, appraising all available evidence, and incorporating wider health systems objectives in decision-making, can be applied to decisons about how LMICs can best utilise basic surgical interventions from within available resources - in essence, to focus spending on the 'best buys'. As South Africa (SA) moves towards National Health Insurance (NHI), HTA functions will be strengthened. There is potential for SA to lead the practice of application of HTA to decisions about how basic surgical interventions are chosen and implemented, contributing to the success and sustainability of NHI in SA and the health of people in LMICs worldwide.


Assuntos
Prioridades em Saúde/economia , Acessibilidade aos Serviços de Saúde/economia , Procedimentos Cirúrgicos Operatórios/economia , Avaliação da Tecnologia Biomédica , Análise Custo-Benefício , Países em Desenvolvimento , Humanos , Programas Nacionais de Saúde , África do Sul
6.
BMJ Open Respir Res ; 3(1): e000145, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28074134

RESUMO

INTRODUCTION: In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating. METHODS: To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review. RESULTS: 82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting ß2-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86. CONCLUSIONS: Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

7.
Rural Remote Health ; 7(4): 805, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17953499

RESUMO

INTRODUCTION: Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program. METHODS: The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation. RESULTS: The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database. CONCLUSIONS: The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.


Assuntos
Acreditação/normas , Educação de Pós-Graduação em Medicina/normas , Avaliação Educacional/métodos , Bolsas de Estudo/normas , Serviços de Saúde Rural/normas , Austrália , Avaliação Educacional/normas , Humanos
8.
Bioethics ; 21(2): 63-74, 2007 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17845490

RESUMO

This paper considers what should be done about offers of organs for transplant that come with racist strings attached. Saving lives or improving their quality seem powerful reasons to accept the offer. Fairness, justice, and rejecting racism seem like powerful reasons against. This paper argues that conditional allocation should occur when it would provide access to organs for at least one person without costing others their access to organs. The bulk of the paper concentrates on defending this claim against these objections: (i) that the good that might come about through conditional allocation does so through wrongful complicity in the racist's wrongdoing; (ii) that conditional allocation symbolizes support for racism; and (iii) that conditional allocation is unjust or unfair and is, for that reason, impermissible. The final section, on conditional allocation as a policy, considers the speculative possibility that conditional allocation would reduce access to organs for some, but it argues that, even then, conditional allocation could be justified.


Assuntos
Seleção de Pacientes/ética , Preconceito , Justiça Social , Doadores de Tecidos/psicologia , Humanos , Masculino , Reino Unido
9.
Intern Med J ; 37(9): 631-6, 2007 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-17714202

RESUMO

The focus of assessment of clinical performance has moved from over-reliance on individual tools to constructing a coherent assessment programme. The purpose of such an assessment programme is to gather high-quality evidence to make well-informed decisions. This requires clarity on the decisions to be made and an ability to gather a sufficient amount of high-quality data. The assessment programme should be aligned to doing the job well so that a successful assessment result reflects what is valued. A variety of assessments over a variety of times, matched against the areas of interest and value, enhances both reliability and validity. Workplace-based assessment tools can complement centralized assessment tools. Multiple snapshots, even if some are not totally in focus, give a better picture than one poorly aimed photograph.


Assuntos
Competência Clínica/normas , Avaliação de Programas e Projetos de Saúde/métodos , Avaliação de Programas e Projetos de Saúde/normas , Humanos , Reprodutibilidade dos Testes
11.
J Med Ethics ; 29(3): 163-4, 2003 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12796436

RESUMO

In a well known British case, the relatives of a dead man consented to the use of his organs for transplant on the condition that they were transplanted only into white people. The British government condemned the acceptance of racist offers and the panel they set up to report on the case condemned all conditional offers of donation. The panel appealed to a principle of altruism and meeting the greatest need. This paper criticises their reasoning. The panel's argument does not show that conditional donation is always wrong and anyway overlooks a crucial distinction between making an offer and accepting it. But even the most charitable reinterpretation of the panel's argument does not reject selective acceptance of conditional offers. The panel's reasoning has no merit.


Assuntos
Doação Dirigida de Tecido/ética , Política de Saúde , Preconceito , Obtenção de Tecidos e Órgãos/ética , Altruísmo , Família , Humanos , Masculino , Princípios Morais , Motivação , Medicina Estatal/ética , Reino Unido
12.
Med Educ ; 36(10): 918-24, 2002 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-12390458

RESUMO

BACKGROUND: The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system. RESULTS: To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes. CONCLUSION: Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general.


Assuntos
Competência Clínica/normas , Educação Médica/normas , Médicos de Família/normas , Avaliação Educacional , Humanos , Equipe de Assistência ao Paciente/normas , Qualidade da Assistência à Saúde/normas , Reprodutibilidade dos Testes , Reino Unido
13.
Med Educ ; 36(10): 949-58, 2002 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-12390463

RESUMO

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.


Assuntos
Competência Clínica/normas , Credenciamento/normas , Educação Médica Continuada/normas , Aprendizagem , Médicos de Família/normas , Qualidade da Assistência à Saúde/normas , Humanos
15.
N Z Med J ; 114(1142): 461-4, 2001 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-11760239

RESUMO

AIMS: To determine the level and sources of medical student debt at the Christchurch School of Medicine. METHODS: A questionnaire, The New Zealand Wellbeing, Intentions, Debt, and Experiences (WIDE) Survey of Medical Students, was developed and administered to all 204 medical students at the Christchurch School of Medicine and Health Sciences. Included were questions on student demographics, sources and levels of debt, parental financial support, and student perceptions of their debt. RESULTS: The response rate was 88%. International students, whose debt was with an overseas government, and students with mortgages were excluded from the data analysis. The combined total debt for the remaining 165 students was $7775000 with $6290000 (81%) owed to the Government Students Loans scheme. One quarter of 6th year medical students had a debt over $83250, 50% had a debt over $70000, and 75% had a debt over $50000. Student allowances were inaccessible to 64% of 4th and 5th year students and part-time employment during term-time was common. Lack of funds was reported to impair full participation in the medical course. CONCLUSION: The majority of medical students at the Christchurch School of Medicine accumulate high levels of debt, mainly dtrough the Government Student Loans scheme, during their medical training.


Assuntos
Educação de Graduação em Medicina/economia , Estudantes de Medicina/estatística & dados numéricos , Apoio ao Desenvolvimento de Recursos Humanos/economia , Financiamento Governamental , Financiamento Pessoal , Humanos , Nova Zelândia , Projetos Piloto , Inquéritos e Questionários , Apoio ao Desenvolvimento de Recursos Humanos/métodos , Apoio ao Desenvolvimento de Recursos Humanos/estatística & dados numéricos
16.
N Z Med J ; 114(1142): 465-7, 2001 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-11760240

RESUMO

AIMS: To record career preferences for medical students at the Christchurch School of Medicine and Health Sciences and investigate factors, including student debt, that might influence career decisions. METHODS: A questionnaire, The New Zealand Wellbeing, Intentions, Debt, and Experiences (WIDE) Survey of Medical Students, was developed and administered to all 204 medical students at the Christchurch School of Medicine and Health Sciences. The survey included questions relating to preferred career intentions and factors influencing career decisions, including the decision to leave New Zealand to practise medicine. RESULTS: The response rate was 88%. 80% intend to practise medicine in New Zealand immediately after graduation, however 82% indicated that they would leave within two years of graduation. Financial opportunities overseas and level of debt were the strongest motivating factors to leave. Repayments towards student loans and increased salaries were factors that might retain people in New Zealand. Medical and surgical specialities were the most popular career choices. Personal interest was the strongest motivator for career choice. Practising in a rural community was not popular. CONCLUSION: Debt is one of a number of important factors influencing medical student career decisions including the decision to leave New Zealand. Initiatives addressing debt may be useful in retaining medical graduates in this country.


Assuntos
Escolha da Profissão , Estudantes de Medicina/psicologia , Apoio ao Desenvolvimento de Recursos Humanos/economia , Adulto , Educação de Graduação em Medicina/economia , Emigração e Imigração , Financiamento Governamental , Financiamento Pessoal , Humanos , Motivação , Nova Zelândia , Área de Atuação Profissional/economia , Estudantes de Medicina/estatística & dados numéricos , Inquéritos e Questionários
17.
Sex Transm Dis ; 26(5): 291-5, 1999 May.
Artigo em Inglês | MEDLINE | ID: mdl-10333284

RESUMO

BACKGROUND AND OBJECTIVES: Accurate human immunodeficiency virus (HIV) surveillance data is critical for the allocation of resources for care services and community prevention planning efforts. GOAL OF THIS STUDY: To validate HIV status of women and assess risk factor information on all persons reported with either heterosexual transmission or no identifiable risk factor. STUDY DESIGN: The surveillance database is updated continually as additional information is received on all cases allowing continual monitoring of pregnant and nonpregnant women. Repeated queries of various record systems were employed to validate or reclassify reported heterosexual or no identifiable risk factor information for both men and women. RESULTS: Four pregnant women (24%) and one nonpregnant woman (0.4%) initially meeting HIV surveillance criteria were demonstrated not to be infected. Risk factors were validated or reclassified for 77 (58%) patients initially reported with heterosexual transmission or no identifiable risk. CONCLUSION: HIV surveillance should be a dynamic process and continual updating of case reports provides the most accurate information on which to base service and prevention decisions.


Assuntos
Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Vigilância da População , Complicações Infecciosas na Gravidez/epidemiologia , Adulto , Coleta de Dados , Bases de Dados Factuais , Feminino , Necessidades e Demandas de Serviços de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Missouri , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/legislação & jurisprudência , Gravidez , Fatores de Risco
20.
N Z Med J ; 109(1017): 72-3, 1996 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-8606822

RESUMO

AIMS: To evaluate the effect of regular input by a geriatrician to an orthopaedic ward. METHOD: A geriatrician saw all patients aged over 65 years admitted to an acute orthopaedic ward-this was compared to an adjacent orthopaedic ward which had consultation only service, and also to both wards in the preceding year. All subjects over the age of 65 years with fractured neck of femur admitted over a 4 month period were enroled. Main outcome measures were length of stay, cost, discharge destination. RESULTS: In the year prior to study, patients in both wards had a mean total stay of 28 days. On the intervention ward the mean stay was reduced to 20.7 days, and on the control ward to 27 days. The cost per case on the intervention ward was NZ$9400, and on the control ward was NZ$11 500. Eleven percent went to a higher care level on the intervention ward, compared with 23% on the control ward. CONCLUSION: Geriatrician input on a twice weekly basis to all patients over 65 years of age on an orthopaedic ward, saves bed days, reduces costs and produces an improved outcome.


Assuntos
Fraturas do Colo Femoral/reabilitação , Geriatria , Encaminhamento e Consulta , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Colo Femoral/economia , Avaliação Geriátrica , Humanos , Tempo de Internação , Masculino , Resultado do Tratamento
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