Resource allocation in health care and the role of personal autonomy.

Resource allocation decisions in health care require the consideration of ethical values. Major ethical theories include Amartya Sen's capability approach, Norman Daniels's theory of justice for health, and preference utilitarian theory. This paper argues that while only preference utilitarian theory explicitly considers the impact of an individual's actions on others, all 3 theories agree in terms of providing individual autonomy. Furthermore, it shows that all 3 theories emphasise the role of informed preferences in securing individual autonomy. Still, stressing personal autonomy has limited direct implications for priority setting. 2 priority rules for resource allocation could be identified: 1) to give priority to patients with mental disability (over those with pure physical disability); and 2) to give priority to patients with a large expected loss of autonomy without treatment.

Cost-effectiveness analysis in health care based on the capability approach.

It is well known that Sen's capability approach and preference utilitarianism have different distributional values. The purpose of this paper is to discuss how Sen's capability approach might be operationalised for allocation decisions and cost-effectiveness analysis in health care. The paper identifies several requirements for measuring health or well-being in line with the capability approach. Among them is the need for objective assessments of capabilities. This paper also shows that from the perspective of the capability approach a portion of productivity changes are irrelevant for allocation decisions.

[Methods of health economic evaluation for health services research]. / Methoden der gesundheitsökonomischen Evaluation in der Versorgungsforschung.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[Impact of demographic changes on health care expenditure in Germany: an analysis considering the expenditures of decedents]. / Einfluss der demographischen Entwicklung auf Gesundheitsausgaben in Deutschland: Eine Analyse unter Berücksichtigung der Ausgaben Versterbender.

The purpose of this study was to evaluate the impact of demographic changes on future health care expenditure of the German social health insurances considering the expenditures of survivors and decedents by age. The study analysed data from 269,646 members up to the age of 99 years of the AOK - one of Germany's largest social health insurers - in the State of Hesse in 2000/2001. In order to determine future health care expenditures, per-capita expenditures by age for outpatient, inpatient, rehabilitation, and nursing services of survivors and decedents (death within the next 12 months) were multiplied by the estimated number of survivors and decedents by age in Germany in 2020, 2035 und 2050. Expenditures for all ages were summed together. The paper shows that demographic changes until 2050 will lead to an increase of health care expenditures by 20% in total or less than 1% annually. Considering the future re-duction in workforce, demographic changes until 2050 will result in an estimated increase in health care expenditures per employee by about 57% (undifferentiated model). Considering the cost of survivors and decedents separately, this increase will amount to 50%. Hence, undifferentiated models overestimate the impact of demographic changes by about 10%.

[Socioeconomic burden of hip fractures in Germany]. / Sozioökonomische Bedeutung von Hüftfrakturen in Deutschland.

BACKGROUND AND OBJECTIVE: Treatment of hip fractures is a major challenge for the German health-care system due to the increasing incidence, high mortality rate, and need for long-term care. The purpose of this study was to determine the present and future economic burden of hip fractures in Germany. METHODS: Annual costs of hip fractures were determined from a societal perspective, by multiplying individual lifetime costs at different ages by the incidence of hip fractures (incidence-based cost-of-illness study). To calculate individual lifetime costs, a Markov decision model was developed. Secondary data were used. RESULTS: Total annual costs related to hip fractures were euro 2.77 billion. Due to population aging, costs of hip fractures may increase to euro 3.85 billion in 2030. CONCLUSION: The result implies the need to identify effective prevention strategies for hip fractures and evaluate their cost-effectiveness.

Direct costs of pediatric diabetes care in Germany and their predictors.

INTRODUCTION: Cost-of-illness study to evaluate diabetes-related direct costs for the care of diabetic children and adolescents in Germany from the perspective of the statutory health insurance. MATERIAL AND METHODS: For all continuously treated patients < 20 years of age from 89 pediatric departments (n = 6437, 52 % male, mean age 12.5 [SD 3.8], diabetes duration 5.2 [3.3] years), diabetes-related hospitalization, ambulatory care, insulin management, glucose self measurement, and treatment with antihypertensive drugs in 2000 were ascertained, as well as metabolic control (HbA1c). Costs per patient-year were calculated in Euros (EUR) based on year 2000 prices. Using multivariate regression, the associations between costs and age, sex, diabetes duration, and metabolic control were evaluated. RESULTS: Mean total costs per patient-year were EUR 2611 (interquartile range 1665 - 2807). Blood glucose self measurement, hospitalization, and insulin accounted for 37 %, 26 %, and 21 % of the costs, respectively, followed by ambulatory care (9 %), injection equipment and glucagon sets (7 %), and treatment with antihypertensive drugs (0.1 %). The total costs were significantly increased for higher age, longer diabetes duration, and higher HbA1c (p < 0.01). The costs for hospitalization were significantly associated with pubertal age (10 - 14 years) and poor metabolic control (HbA1c SDS > 5) (p < 0.001). Based on the present estimations, the total direct costs for the care of all diabetic subjects in Germany < 20 years would be EUR 66.8 (95 % CI 65.4 - 68.1) million in 2000. DISCUSSION: Among the direct medical costs of childhood diabetes, the highest economic burden was due to glucose self measurement, hospitalization, and insulin. The costs were considerably higher in adolescents with poor metabolic control, especially the costs for hospitalization. Outpatient education programs in pediatric diabetes care, in particular targeting children with poor metabolic control, should be encouraged, including their evaluation with respect to cost and effectiveness.

Review of quality-of-life evaluations in patients with angina pectoris.

Patients with angina pectoris have a reduced quality of life because of their symptoms, impaired activity and anxiety. However, there is no consensus on the best method of measuring quality of life. A systematic literature search of randomised controlled trials (RCTs) in angina showed that the most common generic questionnaire was the Nottingham Health Profile (NHP) Part 1, and the most common angina-specific measure was the Quality-of-Life after Acute Myocardial Infarction Questionnaire. A comparison of NHP scores with those of the healthy population revealed that patients with angina particularly seem to experience a lack of energy, poor sleep and decreased physical mobility. In the RCTs evaluated, antianginal drugs did not show a significant benefit over placebo in terms of quality of life. As a result of a lack of valid data from RCTs, a strong conclusion regarding the impact of revascularisation procedures on quality of life could not be derived.

Effects of prostaglandins on [Ca2+]i and adenylate cyclase activity in isolated porcine gastric mucous cells.

In porcine gastric mucous cells, isolated enzymatically from the fundic mucosa and enriched by counterflow centrifugation, PGE2 (1 microM) increased adenylate cyclase activity to 225% and, distinct from that documented for other species, also [Ca2+]i, measured fluorimetrically with Fura2/AM, in Ca(2+)-containing and Ca(2+)-free incubation medium to 182% and 165% of control values, respectively. PGF2 alpha, PGD2, the stable prostacyclin analogue iloprost and the thromboxane-mimetic U46619 had no significant effects on adenylate cyclase activity and [Ca2+]i. Histamine (10 microM) stimulated adenylate cyclase activity to 236% of control value, an effect which could be blocked by the H2-receptor antagonist ranitidine. However, histamine and the activators of the cAMP system forskolin and dibutyryl cAMP had no significant effect on [Ca2+]i, indicating that an activation of the adenylate cyclase/cAMP system per se does not result in an increase in [Ca2+]i. These data suggest that prostanoids stimulate adenylate cyclase activity and [Ca2+]i in gastric mucous cells via activation of EP-receptors linked to both second messenger systems.

[Prospective observation of abdominal ultrasound in radiological emergency services: approaches to cost saving]. / Prospektive Observationsstudie zur Abdomen-Sonographie im radiologischen Bereitschaftsdienst einer Universitätsklinik: Ansätze zur Rationalisierung.

PURPOSE: To analyze prospectively abdominal ultrasound in an emergency department (ED) with special emphasis on different routes of obtaining radiology service, reasons for consultation and ordering diagnosis, and to identify strategies for realizing cost savings. MATERIALS AND METHODS: Over a three-month period, the course of events of 295 patients, who entered the ED and underwent on-call sonography, was recorded from the initial presentation to the commencement of treatment, and the results were subsequently evaluated. RESULTS: Of all patients sonographically examined in the ED, 60 % had no prior contact to ambulatory medical services (self-referred, S), 15 % had been sent by a physician (physician-referred, P), and 25 % were inpatients. The most frequent reason for consultation was acute abdominal pain in self-referred patients (70 %) and blunt abdominal trauma in physician-referred patients (70 %). Sonography for acute abdominal pain was considered indicated by the examining radiologist prior to the examination in 90 % (P) and 70 % (S). Sonography contributed to the diagnosis in 44 % (P) and 22 % (S). Patients had to be hospitalized in 80 % (P) and 40 % (S), and needed immediate treatment in 78 % (P) and 43 % (S). Sonography after blunt abdominal trauma was considered appropriate in 90 % (P) and 65 % (S). Diagnostic information was obtained in 90 % (P) and 88 % (S), and therapeutic interventions were required in 10 % (P) and 0 % (S). The admission rate was 97 % (P) and 29 % (S), respectively. CONCLUSIONS: In the ED, sonography was performed with significantly lower clinical effectiveness on self-referred than on physician-referred patients. Substantial cost-savings could be achieved by more selective use of abdominal sonography for self-referred patients.

The cost-effectiveness of screening strategies for amblyopia: a preliminary report.

Five screening strategies for amblyopia in different age groups were compared according to a decision-analytical model from the perspective of the health insurance funds. Our findings indicate that the costs per detected case of amblyopia range from about 1200 DM to 3000 DM (613 Euro to 1534 Euro). The two most cost-effective screening strategies were to screen high-risk children up to the age of one by ophthalmologists and to screen all children up to the age of one by ophthalmologists. The screening of high-risk children identifies only about a third of all affected children in this age group, when compared with the number of cases detected by screening all children up to the age of one. However, the average cost per detected case of amblyopia among high-risk children is lower than the cost of screening all children in this age range.

[Development of an evidence-based questionnaire for evaluating the structural quality of providers]. / Beurteilung der Strukturqualität von Leistungserbringern. Entwicklung eines evidenzbasierten Fragebogens.

The goal of this paper is to present the method used to develop an evidence-based questionnaire for the evaluation of the structural quality of provider institutions. Structural features addressed in the questionnaire are validated by study-based evidence for a relationship with improved outcome quality. For the purpose of identifying relevant studies, a systematic review and evaluation of the literature was performed. The questionnaire contains the following items: continuous medical education with interactive elements (yes/no); use of evidence-based clinical practice guidelines (yes/no); implementation of a computer alert system to prevent injury from adverse drug events (yes/no); and annual diagnosis- or procedure-specific volumes for each department, providing physician, and senior consultant (threshold volume met or not).

The effect of managed care penetration on hospital staffing in Tennessee, 1991--1995.

The author analyzed secondary data from Tennessee hospitals (1991-1995) to determine what effect, if any, managed health care plans had on hospital staffing. The results of the study, which incorporated multiple regression analysis, revealed an increase in the number of administrative hospital employees on average, with additional interesting effects on the skill-mix of nursing staff. The author believes that, overall, the increase in the number of registered nurses, together with the decrease in the number of licensed practical nurses, does not confirm notions that managed care would lead to a decrease in hospital skill-mix. Since a higher nursing skill-mix is associated with a lower inpatient mortality, managed care may contribute to an improvement in outcomes' quality of hospitals.

Clinical and cost-effectiveness of primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting: model based on the KORA Survey 2000.

AIMS: To analyse the clinical and cost-effectiveness of the primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting using population-based data (KORA Survey in Augsburg, Germany, total population approximately 600,000). METHODS: Decision analytic model, time horizon 3 years. INTERVENTIONS: Staff education, targeted screening and lifestyle modification or metformin in people aged 60-74 years with a body mass index of > or = 24 kg/m(2) and prediabetic status (fasting glucose 5.3-6.9 mmol/l and 2-h post load glucose 7.8-11.0 mmol/l) (target population approximately 72,500), according to the Diabetes Prevention Program trial. MAIN OUTCOME MEASURES: Cases of Type 2 diabetes prevented, cost (Euro), incremental cost-effectiveness ratios (ICERs). RESULTS: Under model assumptions, 14 908 people in the target population would develop diabetes if there was no intervention, 184 cases would be avoided with lifestyle intervention and 42 cases with metformin intervention. From the perspective of statutory health insurance and society, costs for lifestyle modification were 856,507 euro (574,241 pounds) and 4,961,340 euro (3,326,307 pounds), respectively, and for metformin 797,539 euro (534,706 pounds) and 1,335,204 euro(895,181 pounds). Up to 5% of the costs were due to staff education and up to 36% to screening. Lifestyle was more cost effective than metformin. ICERs for lifestyle vs. 'no intervention' were 4664 euro (3127 pounds) and 27,015 euro (18,112 pounds) per case prevented from the statutory health insurance and societal perspective. CONCLUSIONS: Total cost and cost per case of diabetes avoided was high. Staff education and screening had a considerable impact. In view of the low participation in a routine healthcare setting, with both strategies only a small number of cases of diabetes would be prevented. Before implementing the programme, efforts should be made to improve patient participation in order to achieve better clinical and cost-effectiveness of the prevention of Type 2 diabetes in 'real world' clinical practice.

Is subjective well-being a useful parameter for allocating resources among public interventions?

Scarce public resources require trade-offs between competing programs in different sectors, and the careful allocation of fixed resources within a single sector. This paper argues that a general quality of life instrument encompassing health-related and non-health-related components is suitable for determining the best trade-offs between sectors. Further, this paper suggests that subjective well-being shows the properties crucial to a general quality of life measure and has additional advantages that makes it particularly useful for the allocation of public and health care resources. The paper argues that Western societies are in an unusually prosperous situation today which allows to concentrate efforts not only on reducing harm but also on improving positive states of health. Further, subjective well-being can be evaluated from the patient's perspective and incorporates a valuation of life expectancy. Criteria required for an appropriate questionnaire that measures subjective well-being are presented.

[Coronary artery diseases in infants and children. A review]. / Koronaraterien-Erkrankungen im Säuglings- und Kindesalte. Eine Ubersicht.

Coronary artery disease of infants and children are reported. The paper deals with congenital coronary anomalies which appear either isolated or in combination of cardiac or vascular malformations. Acquired coronary diseases appear with periarteriitis nodosa, Kawasaki syndrome, arteriopathia calcificans and infantile arteriosclerosis. It is referred to etiology, clinical symptoms and therapy for each group of coronary disease with an emphasis on prevention.

A method for assessing the cost-effectiveness and the break-even point of clinical practice guidelines.

Assessing the costs and benefits of developing a clinical practice guideline is important because investments in guidelines compete with investments in other clinical programs. Despite the considerable number of guidelines in many industrialized countries, little is known about their costs and cost-effectiveness. The authors have developed specific measures to determine the cost-effectiveness of guidelines, using a German evidence-based guideline on obesity for the diagnosis and treatment of obese patients as a model. The measures are: the number of people needed to cure, the number of people needed to prevent from developing the disease in question, and the number of people to treat in order to break even.