Use Of Scarce Health Care Resources Research Articles

Value for Money in Changing Clinical Practice: Should Decisions about Guidelines and Implementation Strategies Be Made Sequentially or Simultaneously?

Decisions about clinical practice change, that is, which guidelines to adopt and how to implement them, can be made sequentially or simultaneously. Decision makers adopting a sequential approach first compare the costs and effects of alternative guidelines to select the best set of guideline recommendations for patient management and subsequently examine the implementation costs and effects to choose the best strategy to implement the selected guideline. In an integral approach, decision makers simultaneously decide about the guideline and the implementation strategy on the basis of the overall value for money in changing clinical practice. This article demonstrates that the decision to use a sequential v. an integral approach affects the need for detailed information and the complexity of the decision analytic process. More importantly, it may lead to different choices of guidelines and implementation strategies for clinical practice change. The differences in decision making and decision analysis between the alternative approaches are comprehensively illustrated using 2 hypothetical examples. We argue that, in most cases, an integral approach to deciding about change in clinical practice is preferred, as this provides more efficient use of scarce health-care resources.

Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial

Objective To determine whether, from a health provider and patient perspective, surgical stabilisation of the spine is cost effective when compared with an intensive programme of rehabilitation in patients with...

Adult spontaneous hypoglycaemia

Spontaneous hypoglycaemia is not a diagnosis, but a manifestation of a disease process. It is important to recognize spontaneous hypoglycaemia, as treatment may be preventative or curative. It is equally important to avoid mislabelling healthy individuals as having hypoglycaemia as this may have a negative impact on the quality of life and use of scarce health-care resources.

Neck and Back Pain in the Elderly.

Surgical intervention for neck and back pain in elderly patients without significant comorbidities can significantly improve a patient's symptoms and quality of life when more conservative therapies fail. Current spine literature strongly supports the paradigm of treating elderly patients with stable, chronic neck or back pain with conservative therapies first in order to optimize the risks and benefits of all available treatment options. If less-invasive methods fail to achieve satisfactory outcomes, more aggressive surgical options can, at that time, typically be implemented with excellent results in elderly patients without significant comorbidities. Clinical scenarios threatening to result in spine instability or nerve root or spinal cord compression require immediate intervention, especially in elderly patients, who, in general, have a higher risk of developing such conditions either through falls or trauma or acquired degenerative disease processes or malignancies. When an elderly patient enters a physician's office and asks "doctor, I've had pain for years, but it's getting worse. At my age, is it really worth having surgery?" The answer is a qualified "yes," if conservative treatments have failed and if the patient is otherwise in reasonably good health. Because the vast majority of these patients first interact with the medical system through their primary care doctors and neurologists, early recognition of situations requiring immediate attention, and those requiring referrals to spine specialists, can greatly expedite the appropriate use of scarce healthcare resources. Furthermore, knowledge of the various treatment options available to elderly patients complaining of the very common symptoms of neck or back pain can significantly improve patient care, especially in this new century when older patients will increasingly become a larger and more active force in all aspects of our society.

Estimates of the lifetime costs of breast cancer treatment in Canada

A comprehensive understanding of the cost components of common illnesses is a necessary first step towards ensuring optimal use of scarce healthcare resources. Since breast cancer is the commonest malignancy affecting Canadian women, we estimated the direct healthcare costs associated with the lifetime management of a cohort of 17 700 women diagnosed in 1995. Using a multiplicity of data sources, treatment algorithms, follow-up and disease progression patterns were determined by age (<50; ⩾50 years) for all four stages of breast cancer at diagnosis, as well as for the management of local and distant recurrence. Statistics Canada's Population Health Model (POHEM) was used to integrate the data from the different sources and to estimate the lifetime costs, discounted at 0, 3 and 5% rates. The average undiscounted lifetime cost per case of treating women diagnosed with breast cancer varied by stage, from $36 340 for stage IV or metastatic disease, to $23 275 for stage I patients. The total cost of treatment for the cohort diagnosed in 1995 was estimated to be over 454 million Canadian dollars. Hospitalisation (mainly for initial treatment and terminal care) represented 63% of the lifetime costs of care delivery. Disease costing models are valuable tools for optimising the use of scare resources without compromising the health status of individual patients. The breast cancer costing model has recently been used to assess the cost impact and cost-effectiveness of providing radiotherapy to all patients undergoing breast surgery, and of performing outpatient breast surgery.