Considerations For Policy Makers Research Articles

Healthcare Costs and Obesity Prevention

Obesity is a major contributor to the overall burden of disease (also reducing life expectancy) and associated with high medical costs due to obesity-related diseases. However, obesity prevention, while reducing obesity-related morbidity and mortality, may not result in overall healthcare cost savings because of additional costs in life-years gained. Sector-specific financial consequences of preventing obesity are less well documented, for pharmaceutical spending as well as for other healthcare segments. To estimate the effect of obesity prevention on annual and lifetime drug spending as well as other sector-specific expenditures, i.e. the hospital segment, long-term care segment and primary healthcare. The RIVM (Dutch National Institute for Public Health and the Environment) Chronic Disease Model and Dutch cost of illness data were used to simulate, using a Markov-type model approach, the lifetime expenditures in the pharmaceutical segment and three other healthcare segments for a hypothetical cohort of obese (body mass index [BMI] >or=30 kg/m2), non-smoking people with a starting age of 20 years. In order to assess the sector-specific consequences of obesity prevention, these costs were compared with the costs of two other similar cohorts, i.e. a 'healthy-living' cohort (non-smoking and a BMI >or=18.5 and <25 kg/m2) and a smoking cohort. To assert whether preventing obesity results in cost savings in any of the segments, net present values were estimated using different discount rates. Sensitivity analyses were conducted across key input values and using a broader definition of healthcare. Lifetime drug expenditures are higher for obese people than for 'healthy-living' people, despite shorter life expectancy for the obese. Obesity prevention results in savings on drugs for obesity-related diseases until the age of 74 years, which outweigh additional drug costs for diseases unrelated to obesity in life-years gained. Furthermore, obesity prevention will increase long-term care expenditures substantially, while savings in the other healthcare segments are small or non-existent. Discounting costs more heavily or using lower relative mortality risks for obesity would make obesity prevention a relatively more attractive strategy in terms of healthcare costs, especially for the long-term care segment. Application of a broader definition of healthcare costs has the opposite effect. Obesity prevention will likely result in savings in the pharmaceutical segment, but substantial additional costs for long-term care. These are important considerations for policy makers concerned with the future sustainability of the healthcare system.

Association Versus Causation Versus Quality Improvement: Setting Benchmarks for Lymph Node Evaluation in Colon Cancer

There has been substantial attention and interest directed toward improving the quality of medical care in the United States; the need for quality improvement has reached the consideration of policy makers, providers, payers, and patients. In response to congressional mandates, the Institute of Medicine launched the Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Project ( 1 ), with the goal of accelerating the diffusion and pace of quality improvement efforts. Specific policies have been promoted to improve care, including measurement and reporting of performance data, payment incentives, and quality improvement initiatives. Measures in oncology are under active development, and as this process evolves, it is likely that implementation of performance measures will become mandatory and that the scope will broaden. Lymph node evaluation is a frequently discussed potential quality measure for colon cancer, and benchmarks for adequacy of lymph node evaluation have been proposed. As Chang et al. ( 2 ) point out, “the number of lymph nodes recovered from a patient with colon cancer has been identified as a potentially important measure of the quality of cancer care by many organizations, including the American College of Surgeons, the American Society of Clinical Oncology, the National Comprehensive Cancer Network, the National Quality Forum, healthcare insurance providers, and others.” This paper, a systematic review of the evidence associating lymph node harvest in colon cancer and clinical outcomes is, therefore, both timely and topical. In a pooled analysis including more than 60 000 patients ( 2 ), the authors found that 16 of 17 national and international studies demonstrated improved survival as the number of lymph nodes evaluated increased in patients with stage II colon cancer. In addition, four of six studies reported a positive association between lymph node number and survival among patients with stage III colon cancer. The authors conclude that given the evidence, lymph node evaluation deserves consideration as a quality measure for colon cancer care. However, before lymph node benchmarks are established as a quality measure, two important questions must be addressed. First, who or what is being evaluated when we report lymph node counts — the surgeon, the pathologist, the hospital, the patient, or even the tumor?

The Educational Impact of ACGME Limits on Resident and Fellow Duty Hours: A Pre???Post Survey Study

To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003. All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction. The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05). This study shows that it may be possible to reduce residents' hours--and the perceived adverse impact of fatigue--while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.

Influence of varied parking tariffs on parking occupancy levels by trip purpose

The potential impact of parking-pricing on trip generation and modal choice is gaining greater acknowledgement within transport demand management research. However, although the aggregate effect of a transport demand management pricing measure is often noted or estimated, the potential varied impact of pricing measures on specific subsets of the market are often overlooked in the policy process. The variance of price impacts on different trip purposes, initially, and as tariffs increase progressively, is an important consideration for policy makers. Using the results from a survey on 1007 on-street parkers in Dublin, Ireland, this paper shows a progressively widening gap in price sensitivity between trips made for business purposes relative to non-business purposes, as the suggested parking pricing scenarios are increased. The results highlight the complication that the varied price sensitivity of particular market subsets can bring to development of a pricing policy and warns of threshold points where the gap between the price responsiveness of specific market subsets become considerably more pronounced.

Economic, political and ethnic influences on end-of-life decision-making: a decade in review.

Implementation of the Patient Self Determination Act (PSDA) a decade ago has been followed by considerable research examining usage of advance directives among patient populations as well as among health care professionals. This article summarizes the history of end-of-life medical treatment options and provides a discussion of critical economic, political, and legal events that preceded passage of the PSDA. A review of the literature during the decade that followed is presented including research exploring ethnic factors in the completion of advance directives. Barriers to completing advance directives by minority populations are discussed and considerations for policy makers are provided.

An Agenda for Meeting the Special Needs of Multiple Birth Families

Over 80,000 multiple birth babies are born each year in the U.S. Their families must cope with a constellation of complex physical and psychosocial challenges, which jeopardizes their health and functioning. The demands of twin pregnancy and the parenting of twins, triplets, quadruplets, quintuplets or more puts these families at disproportionately high risk for infant mortality, birth defects, child abuse, substance abuse, financial problems and marital problems. Health and social service resources must be developed to alleviate the stresses associated with multiple birth and to empower parents to cope well. Guidelines for policies, parent education, professional training and service delivery developed for the California Department of Health Service, Maternal and Child Health Branch, are here offered for the consideration of policy makers and public health planners.

The economic impact of uncertainties associated with energy-saving technologies

We will analyze the economic sensitivity of new energy-saving technologies to weather, future energy price, and system lifetime uncertainties. Graphical rate of return analysis is employed. A representative residential solar water heating investment is analyzed to illustrate the impact of uncertainties. The wide range of reasonable rates of return found suggests some considerations for policy makers and some areas of future research.

Allocation of Responsibilities and Resources among the Three Levels of Government

There have been many studies of the allocation of responsibilities and services among the various levels of government in the United States, but some of them have not been objective; they have advocated transfers from one level to another because of a desire to be rid of a costly activity. The question of how best to allocate services cannot be sepa rated from the availability of tax resources. But the inci dence of the principal taxes in America has shifted radically throughout our history. Services should be allocated on the basis of optimum administrative and policy-making considera tions, and architects of these optimum arrangements should demand that the appropriate adjustments be made in the tax structure. A detailed examination of administrative and policy-making realities indicates that a number of changes are in order: (1) the states should extend their control over bank ing, public and private housing, roads, narcotics, civil rights, natural parks, labor relations, public assistance, elections ad ministration, factory inspection, agriculture, uses of leisure, and intrastate utilities. (2) Fragmentized services like pub lic health and education should be taken out of small districts and administered by units large enough to permit profession alization and specialization. (3) Services which are essen tially national in scope, like military training and the regula tion of insurance, should be transferred from the states to the federal government. Finally, we should promote an exten sion program of functional consolidation of local governments.