Appraisal of health care: from patient value to societal benefit

Aim

This paper summarizes the deficiencies and weaknesses of the most frequently used methods for the allocation of health-care resources. New, more transparent and practical methods for optimizing the allocation of these resources are proposed.

Method

The examples of quality-adjusted life years (QALYs) and efficiency frontier (EF) are analyzed to describe weaknesses and problems in decisions regulating health-care provision. After conducting a literature search and discussions with an international group of professionals, three groups of professionals were formed to discuss the assessment and appraisal of health-care services and allocation of available resources.

Results

At least seven essential variables were identified that should be heeded when applying the concept of QALYs for decisions concerning health-care provision. The efficiency frontier (EF) concept can be used to set a ceiling price and perform a cost-benefit analysis of provision, but different stakeholders—a biostatistician (efficacy), an economist (costs), a clinician (effectiveness), and the patient (value)—could provide a fairer appraisal of health-care services. Efficacy and costs are often based on falsifiable data. Effectiveness and value depend on the success with which a particular clinical problem has been solved. These data cannot be falsified. The societal perspective is generated by an informal cost-benefit analysis including appraisals by the above-mentioned stakeholders and carried out by an authorized institution.

Conclusion

Our analysis suggests that study results expressed in QALYs or as EF cannot be compared unless the variables included in the calculation are specified. It would be far more objective and comprehensive if an authorized institution made an informal decision based on formal assessments of the effectiveness of health-care services evaluated by health-care providers, of the value assessed by consumers, of efficacy described by biostatisticians, and of costs calculated by economists.     

Oral health: a challenge for the health care team

The objective of this study is to reveal the knowledge of nursing and medicine students from a university in Rio Grande do Sul regarding the importance of promoting dental health. A questionnaire with three semi-structured questions was answered by 26 students from the nursing school, and by 32 students from the medical school. Through the method of triangulation it was concluded that these students had deficient knowledge regarding dental health. Since a small number of the population in Brazil has access to dental clinics, we consider important that nursing and medicine professionals know how to promote dental care among children.     

Breaking bad news during prenatal care: a challenge to be tackled

Communicating an unfavorable diagnosis during prenatal care is a growing challenge in clinical practice, as more and more tests are being performed to screen for the main conditions affecting the pregnant woman and her fetus. The way patients receive and subsequently deal with bad news is directly influenced by how the news is communicated by the attending physician. Unfortunately, physicians receive little or no training in communicating bad news, and they generally feel quite uncomfortable about doing so. Although many physicians consider the saying that "there's no good way to break bad news" to be the truth, the maxim does not reflect the true picture. The scope of this article is to discuss, in light of the scientific literature and the experience of fetal medicine services, some recommendations that can help to deal with these difficult moments and improve patient care for the remainder of the pregnancy.     

Medication regimens and the home care client: a challenge for health care providers

This paper synthesizes literature related to medication-taking behaviors of the elderly population and examines factors related to medication compliance problems. A review and critique of the literature focused on interventions and strategies for improving medication compliance is also presented. This analysis provides direction for developing assessment guides, intervention strategies, and educational materials which may be helpful for health providers in assisting patients and families to manage medication regimens. The paper also includes a comprehensive medication assessment guide and a resource list of educational materials for family care-givers and health providers. The last section of the paper describes the clinical testing study of the medication assessment guide.     

Technical health care models: from the pyramid to the circle, a possibility to be explored

The technical health care model that portrays the health system as a pyramid with ascending and descending flows of users obtaining access to differentiated levels of technological complexity within articulated reference and counter-reference processes has been conceived as a rationalizing perspective, the merit of which would be to provide greater efficiency in the use of resources, in addition to universal, equitable access. In practical terms, by assuming that facts occur differently than intended under a certain technocratic rationality, the author provides some explanations for this "distortion". He also defends the idea that the health system would be more adequately thought of as a circle, containing multiple "portals of entry" located at several points in the system rather than at a presupposed "base". The author also questions the sense of a "top level", a kind of expression related to a certain "technological hierarchy" with the hospital occupying the apex. At the same time he highlights the health system as an entity to be organized focusing on what is most relevant to each user, offering the most adequate technology in the right place and at the most appropriate time.     

Cocaine and pregnancy: a challenge for health care providers

There is an alarming increase in the number of individuals using cocaine in this country. As many as 10 percent of all pregnant women have used cocaine one or more times during their pregnancy. The rising number of pregnant cocaine abusers who present themselves for medical services is creating a challenge for health care practitioners. This article addresses the biopsychosocial issues of cocaine abuse during pregnancy, including the medical impact of cocaine abuse on pregnant women and their newborn infants, behavioral manifestations of cocaine abusers that create health care management problems, and social work's contribution to the health care management of these women.     

Medical students as health coaches,and more: adding value to both education and patient care

New ways of thinking about medicine and health care demand new methods in medical education. Over the past two decades, as both the practice and the study of medicine have become increasingly concerned with demonstrable outcomes, medical schools have developed new curricula in health systems science and are increasingly emphasizing students’ development and demonstration of skills essential to a systems-based, outcomes-oriented practice environment.Polak and colleagues recently reported the development in Israel of one such curriculum, in lifestyle medicine, that includes opportunities for students to adopt the role of health coach. This commentary describes additional recent curricular developments elsewhere with similar goals, but utilizing more ambitious approaches that embed students in medical practices and provide meaningful, ongoing responsibility for assisting in the care of patients. These emerging new models for ambulatory care education, through a construct known as “value added education,” can simultaneously benefit both educational and patient care outcomes.     

Medical necessity, benefit and resource allocation in health care

Many health care systems espouse medical necessity, or need, as a guiding principle for the allocation of resources. Yet, logic and experience suggest that it is likely impossible to develop a concise, explicit, operational definition of medical necessity that would allow it to be used as an administrative or management tool. Even if such a definition could be developed, it would likely do little to solve the fundamental challenges facing policy-makers attempting to reform health care systems. This implies that we should refrain from further efforts to define medical necessity operationally. But does it follow that medical necessity is an empty concept? No. Even if it cannot be defined precisely, it can still serve as a guiding principle for health policy. Given that ability-to-benefit is a core concept underlying necessity, we develop a conceptual framework that encompasses alternative notions of benefit and then illustrate some selected implications of alternative benefit notions for processes required to use medical necessity as a guiding principle and for the types of services that would be deemed to produce a benefit.     

The effect of health benefit information on consumers health value, attitudes and intentions

This research explored the effect of health benefit information on individuals’ stated health value, attitudes towards functional/enriched foods, expectations, perceptions, and intentions to purchase a new fibre-enriched fish product. The study used a randomized design involving an experimental group receiving fibre and health information on the product and a control group who did not receive such information. The results indicated that consumers in the experimental group scored higher on the average attitudes towards functional/enriched foods than did consumers in the control group. No significant differences were observed for other variables. Following a value–attitude–behaviour approach, the study proposed a model relating consumers’ health value to their attitudes towards functional/enriched foods, attitudes towards the new functional product and intention to purchase the product, and tested how information affected the structural model. Four of the seven relationships in the structural model proved to be moderated by information. For example, the results indicated that information constrained the association between the health value and product-related health perceptions or hedonic expectations, when individuals had negative attitudes towards the functional/enriched food products. Overall, the study advances the existing literature on the effects of information on consumer behaviour by adding insights into how information simultaneously influenced the mean values and the relationships among the health value, attitudinal factors and intention.     

How and where clinicians exercise power: Interprofessional relations in health care

This study aims to contribute to the limited set of interactional studies of health occupational relations. A “negotiated order” perspective was applied to a multi-site setting to articulate the ways in which clinicians’ roles, accountabilities and contributions to patient care are shaped by the care setting and are influenced by the management of patient pathways. The study responds to the polarized debate between a critical perspective that calls for collaboration as the re-distribution of occupational power, and a functionalist view that argues for better coordination of health care teams. The study draws on data from 63 interviews, 68 focus groups and 209 h of observation across acute and non-acute health services within a state/territory in Australia. The paper reveals the exercise of both “competitive power” and “collaborative power” in the negotiated order of health services. Both forms of power are exercised in all settings. Relationships among clinicians in various occupations are mediated by the expectation that doctors assume responsibility for patient management and coordinating roles in health care teams, and the degree of acuity of particular health care settings. The combination of a negotiated order perspective and its unique application across a whole health system shows the continuation of a broad pattern of power by doctors over those in other roles. The paper also reveals novel criteria for evaluating the extent of power-sharing in interprofessional interaction in case conferences, and a unique quantification of such interaction.