A Qualitative Evaluation of Program Budgeting and Marginal Analysis in a Canadian Pediatric Tertiary Care Institution.

BACKGROUND: Hospitals in Canada are being asked by governments to improve efficiency and do more with fewer resources. Healthcare decision makers are thus driven to find better ways to manage budgets and deliver on their mission. Formal processes of priority setting and resource allocation (PSRA) are one means to this end. OBJECTIVE: This paper reports an evaluation of one such approach, Program Budgeting and Marginal Analysis (PBMA), as applied at a children and women's tertiary care facility in Nova Scotia, Canada. A brief evaluation conducted immediately after the conclusion of the PBMA process was supplemented with a larger retrospective evaluation. METHODS: The retrospective evaluation included 26 face-to-face individual interviews with senior and middle managers who took part in PBMA. Interview transcripts were analyzed against a template consisting of 19 elements of structure, process, attitudes, and outcomes associated with high performance in PSRA. RESULTS: Respondents had a good experience with the implementation of PBMA, and considered it an improvement over past practice. Success was attributed to effective leadership, and substantial efforts to engage staff members. Understanding of economic and ethical principles of decision making was reportedly increased. Areas for improvement included ensuring that everyone participated in good faith, better communication of final results, and stronger follow-through to determine if anticipated changes and benefits in fact occurred. CONCLUSION: The evaluation framework employed here proved useful in assessing the quality of this resource allocation exercise. The results are directly useful to local decision makers, and the identified strengths and weaknesses are broadly consistent with those reported in studies of other organizations.

Olly Olly Oxen Free (or Ally Ally in Free): Playing Hide and Seek in Allocating Resources for Child and Youth Health.

There are powerful arguments for increased investment in child and youth health. But the extent to which these benefits can be realized is shaped by health institutions' priority setting processes. We asked, "What are the unique features of a pediatric care setting that should influence choice and implementation of a formal priority setting and resource allocation process?" Based on multiple sources of data, we created a "made-for-child-health" lens containing three foci reflective of the distinct features of pediatric care settings: the diversity of child and youth populations, the challenges in measuring outcomes and the complexity of patient and public engagement.

Parental views on tissue banking in pediatric oncology patients.

PURPOSE: Research using banked tissue is key to advancing risk-stratification and treatment of children with cancer. Knowledge of parental attitudes to ethical issues arising in tissue banking is very limited but essential in obtaining respectful consent. METHODS: One hundred parents of consecutively diagnosed children with cancer were offered a validated 34-item questionnaire. RESULTS: Respondents (n = 54) included 10 of 16 parents of deceased children. The majority (89%; n = 48) would agree to have tissue sent anywhere in the world but prefer pediatric aims (69%). Most (98%; n = 53) would permit genetic research, if it might improve the child's health, and 76% (n = 41) would permit it, even if no impact was anticipated. A minority (41%) would not allow painful, strictly research procedures, while 15% would regardless of the child's dissent. Just over half (54%; n = 29) wish to renew consent if stored tissue is used for another purpose. Most (98%) believe their child should confirm consent by the age of majority, but only 71% believe the mature child should be able to withdraw consent. A minority (n = 40; 74%) claim few or no rights to research profits; 83% believe these should be used to fund childhood cancer research. CONCLUSIONS: Parents are very supportive of tissue research, including genetic research. A majority of parents would prefer restricting research to pediatric conditions, and to be informed of results, even if of uncertain significance. These findings may assist Institutional Review Boards in assessing parentally perceived risks of research, and researchers in providing consent elements that support parents and adolescents in making fully informed choices.

Are localized intestinal perforations distinct from necrotizing enterocolitis?

BACKGROUND/PURPOSE: Localized intestinal perforation (LP) is thought to be a distinct entity when compared with perforation associated with necrotizing enterocolitis (NEC). Studies have indicated that LP is more amenable to percutaneous drainage and associated with a better outcome. We sought to determine whether LP and NEC could be distinguished based on clinical parameters alone. METHODS: A retrospective review of 40 neonates with gastrointestinal perforations between January 1990 and May 1998 was performed. All had undergone laparotomy and had histologic specimens available for evaluation. RESULTS: Twenty-one neonates had necrotizing enterocolitis (NEC), and 19 had localized perforation (LP) based on histologic criteria. More neonates with LP were exposed to prenatal indomethacin (37% v 5%; P <.05), received intravenous dexamethasone (42% v 10%; P <.05), had umbilical artery catheters (63% v 14%; P <.05), and had a higher white blood cell (WBC) count (27.1 +/- 23.1 v 14.3 +/- 11.5; P <.05). More neonates with NEC had pneumatosis intestinalis (47% v 11%; P <.05). No significant differences existed in enteral feeding (16% LP v 38% NEC) or overall mortality rate (37% LP v 38% NEC). No statistical differences in the timing of perforation or clinical presentation were found. CONCLUSIONS: NEC and LP are difficult to distinguish based on clinical parameters alone. The authors did find associations between LP and prenatal indomethacin, intravenous dexamethasone, umbilical artery catheters, and a higher WBC count. Mortality rate and clinical outcome were nearly identical in both groups. Pneumatosis intestinalis, thought to be pathognomonic for NEC, was seen on abdominal radiograph in 2 babies with histologically proven LP.